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ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department
1146 Route 28, South Yarmouth,MA 02664-4492 Ir 4%.
508-398-2231 ext. 1261 Fax 508-398-0836 �;;F
Massachusetts State Building Code,780 CMR ``
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: at,b I-ODM y Z Date Appli
i a w• RR� S , - u- A MP,Y 2 '`
Building Official(Print Name) Signature m ._ C Date
SECTION 1:SITE INFORMATION ts`
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
33 u' carl Car
1.1 a Is this an accepted street?yes no 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.40,154) 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 caner'of cord:,-e.,rele bfAioli /-a f1 O.ZE< 3
Name City,State,ZIP
33 Ifj¢6+,cr7ov xA/ CRA "Q'Ccr CitieW fJ/6914L ,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 0 I Repairs(s) Q' Alteration(s) 0 I Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: RePL,ce .S`,C J,Oeg .4- o 1 s,CALA, 000A
(,i4-1 folic SI ze ,iLeo SrYJ.c
.414 4 btIt, De car_ 40..1.3( PT A-190o Azeet rot ,ace% Arc7A-ApY
Sir O,ti C 69A.Cite-re pie,e S Soo or4Bei'
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ 4)_( Indicate how fee is determined:
2.Electrical $ N Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ 35
4.Mechanical (HVAC) $ List: f5.Mechanical (Fire C ��
Suppression) $ Total All Fees:$ 3D
Check No. Check Amount: Cash •
6.Total Project Cost: $ LID ea ❑Paid in Full 01 Outstanding Balance e: 44l
S.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ,ge 4//#/IO
�/ //j
/ /Q�'�d iter /t'/ /fU License Number Expiration Date
Name of CSL Holder
a Xi AA Oeiezy 4A y List CSL Type(see below)
No.and Street Type Description
y- o - ( Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&.2 Family Dwelling
City/Town,State,ZIP Iv1 lvlasonry
RC I Roofing Covering
WS Window and Siding
.P 4Jp f,33 y rAotkobetak f cif/Deco/3. SF Solid Fuel Burning Appliances
10441- /Y I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) �O f�6 �23
.�i�G"9.9,441/ OF LPe C.OlO HIC Registration Number /Expiration Date
HIC Compapy Name or HIC Registrant Name
fi
,4" t "fell y ' 4b ',4dfOFCAP &Gicei
No.4nd Streeiitir T 0,63r Email address
City/Town,State,ZIP f Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(N.I.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 ❑ 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 �0�' jI 1 11)Y
to act on my behalf,in all matters relative to work authorized by this building permit application.
(faies �f & �- CAVAf/Ati
Print Owner's Name(Electronic ignature) Date
• SECTION 7b: OWNER'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.
131-4‘,/
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.nov/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"
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The Common wealth of Massachusetts
- t' Department of Industrial Accidents
`_ _= 1 Congress Street, Suite 100
Sit Boston, MA 02114-2017
r4 www.mass.Qov/dta
b
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/organization/individual): 2j 'e �04,(/0rj,141# OF tO' a?
Address: /I 4;/Af 7€.€
City/State/Zip: a f41 r /"d O, 6 $J Phone#: f',.?9cr
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time)."
7. ❑New construction
2.111 I am a sole proprietor or partnership and have no employees working for me in
c aci8. Remodeling
any
ap ty.[No workers'comp. insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t g ❑ Demolition
4.01 am a homeowner and will be hiring contractors to conduct all work on m YP property.e 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.
12.11 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§I(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.
t 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#or Self-ins.Lic.#: 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 1vIGL 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 h pains and penalties of perjury that the information provided above is true and correct.
Signature:
Date: CrA/1/
Phone#: ./0 3JJ�5
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):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:
Phone :
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-22311 ext. 1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 33UA-cefAil"iO v jet/
Work Address
Is to be disposed of oat the following location: ?'WV OF yi��QQ-t� � r✓�S' l�<� "
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
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Signa e o Application Date
Permit No.
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Sears, Tim
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From: Sears, Tim
Sent: Friday, June 4, 2021 2:58 PM
To: 'handymanofcapecod@gmail.com'
Cc: Slack, Christine;Water Department
Subject: 33 Vacation Lane
Krasimir,
I have reviewed your application for the deck addition, and there are some items needed;
\ 1. Health Department sign off
2. Water Department sign off
er
4. Footings are required to be 12" min.
-57--Fort. sp .
Please submit these items for review
This email is considered a written denial of your permit application per Section 105.3.1 of the Massachusetts
State Building Code. Section 105.3.2 states in part that "an application for a permit for any proposed work
shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been
pursued in good faith"
You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100,within 45
days of this notice.
Timothy Sears CBO
Building Inspector
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsears@varmouth.ma.us
1
row.: OF yAR\iourii
WATER DEPARTMENT
%
414; 99 Buck Island Road
%Vest Yarmouth. MA 02673
;! )orly: ,5061 '-1-7921 • rav ',Mil 771- 998
BUILDING PERMIT APPLICATION FOR
NVATER DEPARTMENT SIGN OFF
TR.ANSNIITTAL FORM
3
BUILDING SITE LOCATION: 1464 1O - A/
PROPOSED WORK: &PLACe Aft Dec:ie.
APPLICANT: Rig )ite//e /1": 4/
/—
ADDRESS: Ar LI 14e see,eY te,05' c-Q--reeir /1/44*,
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-7-.4 -2 0 7 3-5' Lf— 17/44,4 0176c0"C CO:44-Uf 624"/
RESIDENTIAL AND OR CONINIERCIAL BUILDING
Water Department: I>etermines Compliance of Water Availability and or existing location
Engineering Department: I)‘..iermines Compliance for Parking and Drainage
('onsen anon Commission I)ctermines Compliance to Wetlands Act: i.e, lints)border any type of
\%et lands. Nt reams.ponds.rivers,ocean. bogs.boys. marshland. ETC...
I lealth Department: I)ctermines Compliance to State and'town Regulations, i.e.
requirements !Or Septage Disposal and other Public I lealth Activites
Fire 1)cpartmcill: I Mermines C'ompliance to State and Town Requirements for Personal
Safety, Property Protections, i.e. Smoke Detectors,Sprinkler Sysleins.ete
7->7
APIItrCANT.SIGN [[RI: DATE
OFFICE USE: COMMENTS ON PERM1.1 APPROVAL OR DENIAL
q/2.0
REVIEW BY ATER DIVISION (SIGNATURE)
DATE
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