BLD-23-05891 .
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department ' -""�-._
1146 Route 28, South Yarmouth,MA 02664-4492 •
if
508-398-2231 ext. 1261 Fax 508-398-0836
Massachusetts State Building Code, 780 CMR e
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only ,,
Building Permit Number: (.� (> j--OR9 l Date Applied: �'_ fV p�, Ars TS-�� �,3 ► lir
APR-
2 10.M
Building Official(Print Name) Signature LB:
NG
SECTION 1:SITE INFORMATION L5Uu1L0t&y_ a�pARrMENr
1.1 Pro erty Address:
3 cd V C5 O(i t Yai On c)tA D( 1.2 Assessors Map&Parcel Numbers
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) Y asd E CE V E D
Front Yard Side Yards Rea
Required Provided Required Provided Required Ped1 r► 2r23
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dispos*l G t�G DEPAin'TMENT
Zone: _ Outside Flood Zone? g
Public 0 Private 0 Check if yes❑ Municipal❑ On site di§'oca swans 1 ---
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: �//
X DALE GEoHA&ANt YArnrwv441 (Part, MA, 0Lfo�l5
Name(Print) City,State,ZIP
X 3 covey Drive, 919 3$1 1222. UN,ok . en11Pelcu(.tar► ,
No.and Street Telephone V
P ail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: r OM/er-Ftnq a (kin,t +n a
iIA J k - a u-f hoc ern en 4- n1 o o r t.t r i ct coy ens ni5 .
A1' VA L '10 Nstrh
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$13-0 Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ 3 (1p
4.Mechanical (HVAC) $ List: I'M do ead-&_)5
5.Mechanical (Fire $
Suppression) Total All Fees:$ ,�
Check No. Check Amount: Cash Amount:
X 6.Total Project Cost: $ 2 0 0 Paid in Full CI Outstanding Balance Due: ��
J
✓ SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted l&2 Family Dwelling
City/Town,State,ZIP Ivi Masonry
RC Roofing Covering
• WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.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
iNt to act on my behalf, in all matters relative to work authorized by this building permit application.
TALE %0/- lf41'� fib 2 3 3
Print Owner's Name(Electronic Signature) /Date
• SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering.my name below,I hereby attest under the pains and penalties of peijuty 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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"
The Common ealth of Massachusetts
- _;� � i Department f Industrial Accidents
=M:if�1= 1 Congre s Street, Suite 100
= f= Boston, MA 02114-2017
IMO •`°. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): DALE CT E V i-f g G A N
Address: c3 Co ve j On ve-
City/State/Zip: /L.xmvv+� or+, Pi A,0475Phone #: gig 3 c'i / 22 2
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑lam a employer with employees(full and/or part-time).*
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 •
3.15aI am a homeowner doing all work myself. [No workers'comp. insurance required.]r 9. ❑ Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Li Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.[II 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•❑Roof repairs
6.0 We 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.
t Homeowners who submit this affidavit indicating they are doing al!work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 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 ains and penalties of perjury that the information provided above is true and correct.
0( Signature: (D .
Date: It/13/2 3
Phone#: I'I q 3 V I 7 2 L2
Official use only. Do not write in this area, to be completed by city or town official. 1
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#:
;o R TOWN OF YARMOUTH
BUILDING DEPARTMENT
°a 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION: 3 Cc7 V e U J f t 1 f \10.r mou- -h Po r f
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" Date.- 6e.o titian 9 I 3 1222.
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS e2) v e
y0.< ?c,( v MA 0 a_ 3.15
CITY OR TOWN STATE ZIP CODE
The current exemption for `Homeowner' was extended to include owner—occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such
homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1)
Definition of Homeowner:
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to
be, a one or two family attached or detached structure assessory to such use and/or farm structures. A person who
constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall
submit to the building official, on a form acceptable to the building official,that he/she shall be responsible for all
such work performed under the buildine permit. (Section 110 R5.1.3.1)
The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned 'homeowner' certifies that he / 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 Di
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes No
If you have checked ves, please 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
h:homeownrlicexemp
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 j G. �f,vL 7Ok(Mou }�cyf
Work Address
ez Is to be disposed of at the following location: /a(m0a,- (Do AreA
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
I Ii / 3
ature of Applicant Date
Permit No.
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