HomeMy WebLinkAboutBLD-23-005376 RECEI \MID& TWO FAMILY ONLY- BUILDING PERMIT
9 Town of Yarmouth Building Department -.'r --
�IAR 29 2023 1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836
Massachusetts State Building Code, 780 CMR
BUILDING DEPAImuldzngPermitApplication To Construct, Repair, Renovate Or Demolish a.�,�
sy:_. —
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 3 bp- 9,3 -1)t374, Date Applied:
Building Official(Print Name) gn re Date
SECTION 1: SITE INFORMATION
1.1 Proper Address 1.2 Assessors Map&Parcel Numbers
1/4,//1.1 a Is this an accepted street? es 1/ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone?
— Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 One i of Re ord: 40 ii
]
Name Print la . " ' ►- 1 C L?U
( ) City,State,ZIP t
y ___Ktt0.1AVOL( ke---- — Attrn'
No.and Street T eph a Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check al hat apply)
New Construction 0 1 Existing Building 0 Owner-Occupied �epairs(s) l Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units / Other 0 Specify:
Brief Description of Proposed or :
A)i t ,e-,d C d 04-Yi- it j
SECTION 4:ESTIMATED CONSTRUCTION COSTS APR 10 2023
Estimated Costs:
Item Official Use Only G DEPARTME
(Labor and Materials) BUILDIN
1.Building $ 1. Building Permit Fee:$�{i O Indicate how fee i NT
"It Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ J
4.Mechanical (HVAC) $ List: .3 5_,(.)O M91a3 f-4
5.Mechanical (Fire $
Suppression) Total All Fees:$ /
Check No. Check Amount: Cash '
/6.Total Project Cost: $ o ❑Paid in Full -*Outstanding Balance e: ��� ��
v \
r SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
j V
`V., .ILAL •/V J� ' Lic4iV ___ ___....ense NumberExp ation Date �3/.4.
of CSL Holder
cy `/� _`C 2 33 List CSL Type(see below)
7
N .an Street 7� Type Description
/ -T to /' 6 2Z j�,�/ Unrestricted(Buildings up to 35,000 Cu.ft.)
Ciowh,State, IP '( ( , Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
•�X�y WS Window and Siding
(c 3'EX1 ( 0 A, SF _ Sold Fuel Burning Appliances
'� �-Z1 ►IC2 "� `� 1�� I Insulation
Telephone Erns .I•;0. ♦6 t ��1's D Demolition
5.2 Registered Home Improvem nt Contractor(HIC)
HIC( Dnipany Nam r-HIC Registrant Name HIC Registration tuber Exp ra ion Date
/ No.and Street
Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(1VI.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes 0 No . ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
S z e w1Gt i 1
Print Owner's Name(Electronic Signature) Date
• SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.2ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) , Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
in kt nod Ze, ka- i t -i- iUvI
The Commonwealth of Massachusetts
1 L Department of Industrial Acciderzts
° ► _= 1 Congress Street, Suite 100
':F Boston, MA 02114-2017
.;S�•'�� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
t/' Name (Business/Organization/Individual)' \JV4 2 }t 4-------„ e-� 1�-u-24��,,,, r y C,
'�`� 'slit C�
Address: A ago,....2 7
t-/ City/State/Zip: X4,fr A( Phone #: 3 - .
Are you an employer?Check the appro iate box:
Type of project(required):
I.❑I am a employer with employees(full and/or part-time)."`
7. 7 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp. insurance required.] 8. [ Remodeling
3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. El Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole
11.0 Electrical repairs or additions
proprietors with no employees.
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.t 13.0 Roof repairs
6. are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
152,§1(4),and we have no employees. [No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy r or Self-ins.Lic.w: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pain and pen ' s of per ry th the information provided above is true and correct.
jSi C --...2-3Date:
P ne T: 61-ect 6 dv _._
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#:
o1'.YA t TOWN OF YARMOUTH
• '� ° BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
JOB LOCATION:
NAME STREET ADDRESS S TION OF TOWN
"HOMEOWNER"
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN : A 1'r, ZIP CODE
The current exemption for `Homeowner' was extended to include ► vner—occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire w o does not possess a license, provided that such
homeowner shall act as supervisor. (State Building Code Sect'an 110 R5.1.3.1)
Definition of Homeowner:
Person(s)who owns a parcel of land on which he/she resi a-s or intends to reside,on which there is or is intended to
be, a one or two family attached or detached structure ass'ssory to such use and/or farm structures. A person who
constructs more than one home in a two-year period sha not be considered a homeowner; such"homeowner"shall
submit to the building official, on a form acceptable to he building official,that he/she shall be responsible for all
such work performed under the building permit. (S- tion 110 R5.1.3.1)
The undersigned `homeowner' assumes respons'.ility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations
The undersigned 'homeowner' certifies that e / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFIC, •
E ISURANCE COVERAGE:
I have a current liability insuran'e policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes No
If you have checked yes, pleas.indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
b
h:homeownrlicexemp
w
TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G. L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at e f
1
Work Address
Is to be disposed of at the following location 412, \ ```�jV, ' -i....45--
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
../" ---- ,,,/ 1
Sig ture of Applicant Date
Permit No.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall •
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02 1 1 4-20 1 7
Tel. rt 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax r 6I 7-727-7749
Revised 02-23-15 www.mass.gov/dia
®c Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Re ulations and Standards
ConSt tj116 'visor
CS-040948 > Expires:07/05/2023
LAWRENCE M NADZEIKA.,
PO BOX 2337' f.
MASHPEE MA�02649 r
VOA.. aJC1,�O
Commissioner , /„
•
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE `Iridiuidual
Registration Expiration
11184! `` 025
LAWRENCE M.NADZEI
LAWRENCE M. NADZEItk" T
2 POINT ROAD '
MASHPEE,MA 02649 Nttr
Undersecretary 1
Fallon, Rosa
From: Joe Madden <jvmacden@gmail.com>
Sent: Wednesday, March 29, 2023 2:27 PM
To: Fallon, Rosa
Subject: Building permit
Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are
sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure.
Otherwise delete this email.
Good Afternoon Rosa,
I just spoke with Mike Nadzeika and I wanted to send 1:his email granting him approval to pull a building permit on my
behalf for the following address:
60 Broadway St Unit 14
West Yarmouth, MA 02673
Please let me know if you have any further questions.
Regards
Joseph Madden
jvmadden@gmail.com
(C): (781)-424-0209
1