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HomeMy WebLinkAboutBLD-23-004026 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department ;,• -""� ,_ 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 1.: `: . 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 R E C E I V E D Building AL Number: L D—2 -- Date Applied: i 1 r^ IeRC5 � �.� JAN 2 0 2023 Building Official(Print Name) Signature - BUILDING—DEPARTMENT SECTION 1:SITE INFORMATION Bye_ 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers ✓'' '/6 6-4'.JJSE 1,A) 1.1a Is this an accepted street?yes JC 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Outside Flood Zone? Private 0 Zone: — Check if yes❑ Municipal 0 On site disposal system SECTION 2: PROPERTY OWNERSHIP` 2.1 Owner'of Record: /r14 7 _M £tJ > Mtm,o'ar•/ ,r/f) o 2.‘23 Name(Print) City,State,ZIP y� 6' Al yr-Zi0 1771 4,2.45//4y GM/Ic- No.and Street Telephone Email Address •<<,:A SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 17/j Repairs(s) 0 Alteration(s) EVAddition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: CUA/�/ti�T • trt- , ,,,.1 4)2;5 /A2 t' AL/9/.0e.n '/z. Aieir SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 2 tot 1. Building Permit Fee:$ 5 6 Indicate how fee is determined: 2.Electrical $ ,� 13 Standard City/Town Application Fee d` 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 3G00, 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 3 .611) 133 5.Mechanical (Fire c� Suppression) $ Total All Fees:$ v �/( Check No. Check Amount: Cash Amount: /6.Total Project Cost: S �,� \/�,J G� �E 0 Paid in Full G5 Outstanding Balance Due: ill) � u 0`� .% 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.)_ City/Town,State,ZIP R Restricted I&2 Family Dwelling M 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 Company Name or HIC Registrant Name HIC Registration Number Expiration Date 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 0 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. 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.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" _ � The Commonwealth of Massachusetts leI i = Department of Industrial Accidents i • ill= 1 Congress Street, Suite 100 f�1 Boston, MA 02114-2017 ..sv�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print LeRi Name (Business/Organization/Individual): / c{2le. e.e-JC S Address: / cr'p as, 4A City/State/Zip: / , �`/-, ,tip D ti j�} Phone #: /F. Z d 1 Z/CI — ( 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 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑RNemw delingconstrlCtlOn any capacity.(No workers'comp. insurance required.] g• Remodeling • 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 4."I"'`I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole l l. Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. i2' Plumbing repairs or additions 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.❑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 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 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 I 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 nder the pains and penalties of perjury that the information provided above is true and correct. Sienature: -^— Date: 2-0 2-3 'Phone 4: lE" -Z., / U c" 7 2. 7E 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#: --�v ; TOWN OF YARMOUTH ma's of �° BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: '/' 6' ,ova; tLA5 j NAME STREET ADDRESS SECTION OF TOWN "HOMF,OWNER°> .5 5/1 Z1 o y2,7E NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS V‘ 4,4i CITY OR TOWN STA Lb 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 building 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 I-�-�- w _ 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 yes, 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 7 ki L',�t�✓S� ��v cv. ri ,�f e,; Work Address / Is to be disposed of at the following location: ,V%,!'NI Gz)—hi D;s/1°,>/4 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. hit //2 ,,/z,) 2- -3 Signature of Applicant Date Permit No. I 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 doe 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 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia • "_ 0 1 r p qb � r T) 7 - ,* tt ( 7-0 ,/z7-; ; , , . 4 (IC 4 , x, d r - c9 b ocN b - c r � cr fi in s` "P"As AINNollIk c , :x. �' 1_ .0., '. sue'"- ,... -�Y�"'*.�s',-- - ,w � '',4,.;::._-'-',:-,-.,.',rtis,.;*-H.,.1.:..,.1-4t.,:,,,,..,,,,,,,..,:it.,..,,:.:',,,,i,:, 4 , .. # i Y„ • .- 4+ - t7 - �,� t't. .. s v ,v! s .' _ - - .. X ''vry� _ 1.4"-,1-"": -.44,-*w-i1.-"-ti.,-,- = ,,,-4' • - -.:-.-. 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