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ONE & TWO FAMILY ONLY- BUILDING PERMIT r -----
Town of Yarmouth Building Department T 1 2022
1146 Route 28,South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836Massachusetts State Building Code,780 CMR (:?.., !1)
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Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 6z 1)43OZ 4IF' Date Applied:
Iir^ SczAt- I),'►Ct' 1-,
Building Official(Print Name) • Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
25' 1i.0 St. yo.vw,.,i-4,- .-•l I, # 0 aid 75 /,23 /5 l/e 01
1.1a Is this an accepted street?yes .< no Map Number Parcel Number -
1.3 Zoning Information: 1.4 Property Dimensions:
,Qy b S k K.,.... „Ji)i--0) 0. 1A 4�.► S is-vs-i-
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 Private 0 Zone: — Outside Flood Zone? pal 0 On site di osal system de
Check if ye, Municisp y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of 1UiRecord: tk.4-v /a
Name(Print) City,State,ZIP
!/ &//Au/ w I'/ ai2 •wet;Pkzee a c_k%l49 3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building( Owner-Occupied 0 I Repairs(s) 0 Alteration(s) K Addition 0
Demolition % Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: 72,...,4, •,ua.L,Qs i- 1 ,rr�,C .4�-r�¢. 1)44...e. 4-
ry ca -e ZAI) 1344- - 'J 1b€ k. . A-4-4i ct}.,: / pj1„ a t .aea.LErs�. /..4.-r
1,.-- A-.J rJ lra 4... W 4- et&o r Tr'µ t 4-0a w--^A. ,�5. ' *..H:. it-i 4-e j 1 4--
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SECTION 4:ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Costs: t Official Use Only
(Labor and Materials) .Uc •
I.Building $ i(,15 14- 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ,j!� Standard City/Town Application Fee
❑Total Project Cost3(Ite )x multiplier x
3.Plumbing $ '24• 5/1- 2. Other Fees: $ Te.d
4.Mechanical (HVAC) $ "t''r List d
5.Mechanical (Fire a`r _ . • 71/Q /1 L
Check No. Check Amount Cash Amount
Suppression)
6.Total Project Cost: $ V' K 0 Paid in Full III Outstanding Balance Due:
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DocuSign Envelope ID:202073D1-3080-4B85-9CF1-AE18136F4C9E
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
es— 1'640.7 10 /24
�/
�Iy►.�.t //• 51.t4 License Number Expiration Date
Name of CSL Holder V
d,• eZ 0 to O List CSL Type(see below)
No.and Street Type Description
tie S 4 Opt 3 t/1r� Unrestricted(Buildings up to 35,000 cu.R)
Ci fI own,Stag ZIP R Restricted Ida Family Dwelling
Q' M Masonry
RC Roofing Covering
• WS Window and Siding
��• 1 l w r
.- SF Solid Fuel Burning Appliances
ri
(oo3-403��Oo1 XS�Qro set• - ,')•Ccr+w- I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /7SSFIO oo�jfs/��3
.i/.•n / t,tee S ii1 C HIC Registration Number Expiration Date
ITC Corn any Name or 1-lC Registrant Name
7 SP�•caFr�1,V 2x9 1.x/lf ""s5���r�c�s .h.ad-
No.and Street Email address
't?e.,n49 ry j1- oo'ZCar SaS.wS'99-p7r��
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT c.152.§25C(6))
Workers Compensation Insurance affidavit must be ccmpleted 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 f7
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 f-%.4/" / ` . es AjL C
to act on m& �g
be�alfndd�y.• all matters relative to work authorized by this building permit application.
ocu
W.ca 24/..(4f 10/22/2022
Print O 'it3iartmadaa tunic Signature) 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 ac`1.to to the best of my knowledge and understanding.
Print Owner'soriAgent's r tectonic 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.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" 1
Commonwealth of Massachusetts
®} Division of Occupational Licensure
Board of Building
,,R,e�ulations and Standards
ConstlW�[ionT$ visor
tP
CS-116602 ti Ftpires: 11/11/2025
FRANK H SOpTT I f
PO BOX 2060r
DENNIS MA `663$ •
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Commissioner daea '.
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10, Mass.gov
0ffrie
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CARf2
HIC Registration Complaints
Registration 175580
Registrant HANLON HOMES INC.
Name JOHN SCOTT
Address 17 SCHOFIELD RD
City, State DENNIS, MA 02636
Zip
Expiration 06/19/2023
Date
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.
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§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. Ch. 40, §54 and i 80 CMR- Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 25—�fn }� r► J� tom` ' � 11 62-6-75
Work Address
disposed of oat the followinglocation: j r
Is to be p
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
441(444-f f l /o 7-e(oLd--
Signature of Application Date
Permit No.
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:\ The Commonwealth of Massachusetts
i.-_. :1, Department ofIndustrialAccidents
�1''`VI
1r. = 1 Congress Street, Suite 100
Boston,MA 02114-2017
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): �.�.o_-_ lid ry`e_S /tie_
Address: /7 5c-40 A e i 12.i . pO. Ed.g `f
CitylState/Zip: .D.t'`4` s, �'� a. --to 3 k _ Phone#: So 9- --S 2-g-- 2-7 vZ 7
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. 11 New construction
Xam a sole proprietor or partnership and have no employees working for me in 8. Remodelin; •
ny capacity.[No workers'comp. insurance required.]
3.0 lam a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. 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 1 1.'Electrical repairs or additions
proprietors with no employees.
12.( Plumbing repairs or additions
5.0 l 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) 13.[]Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemptionI4.Q Other
g p per,�1GL c.
152,§1(4),and we have no employees. (No workers'comp.insurance required.]
*Any applicant that checks box ill 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.
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: fit/is J.t,s.r,._..."c //��y / , l` !VWi.pkr.j ). ,,,,�.�
Policy h or Self-ins.Lic.4: Al� 13�4fN 3 ✓/_bl4l03S13L' i�9� Expiration JDate: is Jac)/ate 3
Job Site Address:) 'WA.n Sf -. City/State/Zip:5/ ;v:t. . -- R -i. M-4 042u 7S
Attach a copy of the workers' compensation policy declaration page(showing the policy d❑mber 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 wider the pains and penalties of perju _-th information provided above is true and correct.
/`� , "nt,L ,
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Sigtiature: Ay e✓ 4fl � - Date: /o,4'� -a---
Phone 4: S O�- 5 J-� e� 7 O+� 1.41r
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License T
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#:
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'CY j 41i �-N
Y TOWN OF YARMOUTH
RECEIVE 4164-4451
�� Telephone(508)398-2231 Ext.YARMOUTH,1146 ROUTE 28,SOUTH 92-Fax( 6 508)398-0836
( OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
rirouOul—
OLD KINQ:SHIGHWAY_1 APPLICATION FOR
CERTIFICATE OF APPROPRIATENESS
Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as
amended,for proposed work as described below&on plans,drawings, photographs, &other supplemental info accompanying this
application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S),ELEVATIONS PHOTOS,&SUPPLEMENTAL INFORMATION.
Check All Categories That Appl : Indicate type of Building: Commercial y R• -
1) Exterior Buildin Construction: New Building N.Addition / 'Iterations Reroo; W r g€E I V E D
nShed Solar Panels Other: n NOV 15 2021
2)Exterior Painting: Siding Shutters t l Doors Trim Other:
3)Signs/Billboards: n New Sin Change to Existing Sign -
BUILDING DEPARTII�ENT
4)Miscellaneous Structures: Fence Wall Flagpole nPool Other: A iiMet)r` —
Please type or print legibly: ��^^�� ` �;
Address of proposed work: ..V,/ 1 c `; w% f[ Map/Lot# A-112/G
Owner(s): 121 A N G f7Y km V , t \ )ci}-t Phone#: 55'0Lf:WI I - 11,)-1,-
All applications must be submitted by owner or�1acompanied by letter from owner approving submittal of application.
Mailing address: 11 i11,..1.4 v 't- W b
1ti W tl 43%1'1441 ) 44.. 0 1 cv Year built: 19170
Email: V WA 11 .4 iL E•'1' 1 1,4 A 4.-, COW% Preferred notification method: —. Phone Email
Agent/contractor: i VV44)1' �t. t`�' '4''i 4 Nt,�4.10k'f }'tt'}Y _Phone#: •til,fer^, .
�[p
Mailing Address: ,0. 2)C 't 24 W NAJ� + t/"1/c b I
Email: Preferred notification method: — Phone J1 Email
Description of Proposed Work:
* T11,9170sota ?r Y 'T 15 rrN PCPC1ill r•1 it Ia or,.) "jp�i
Wi INc, �Iw 4L E- 1- 1M1 Ly I?1 1N tom P JirM-) 1 trtrvCc)
v tmN41 it. N poin.
Signed(Owner or ge ): Date: 2_ '7, .-
Owner/contractor/agent is aware that a permit is required from the Building Department.(Check other 1 : ° i
If application is approved,approval is subject to a 10-day appeal period required by the Act.
This certificate is good for one year from approval date or upon date of expiration of Building Permit;whichever date shall be later.
All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for frarrtrng&,flue!inspections.
j
For Committee use only: 1/Approved Approved with Modifications Denied
Rcvd Date: ice/2 1,#)01;2' Reason for Denial:
Amount .tO
!
Cash/CK#: tY(i 1 VZ�lLy^ �
t1 Signed: ':.1 � ���...,--
Rcvd by: 1..-t '� .
45 Days: r` ✓< ,
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Date Signed:
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APPLICATION#:
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THOMAS A.MOORE DESIGN CO. Z
--+ o _o 8 m , m g7 ,�s & ADAM WAITKEVICH q 25 PINE STREET YARMOUTH PORT,MA BREWSTER,MA. (508)896-6403
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z z o m LI 5gA441 DIANE & ADAM WAITKEVICH P.O.BOX 2124 949 LONG POND RD.
H.�+ P o P N b go 25 PINE STREET YARMOUTH PORT,MA BREWSTER,MA. (508)896-6403