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Home My WebLink AboutBLDR-23-9219 73C-DR- ,3- 92/ 9 \�4v ONE & TWO FAMILY ONLY- BUILDING PERMIT \ ti Town of Yarmouth Building Department ......4--);.---__ 1146 Route 28, South Yarmouth, MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 ' Rk assachusetts State Building Code, 780 CMR FE (7. El3r ' Application n P ' t z A lication To Construct, Repair, Renovate Or Demolish � F _.._ "1 a One-or Two-Family Dwelling NOV 3_ 2021 This Section For Official Use Only t Q AP /�rm(t Numb q U`t, r 1 Date Appli 5, �. e - I l r,r s \`,.�—1,+ Building Official(Print Name) ignature Date SECTION 1: SITE INFORMATION 1.1 Property Apidress: 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) 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: Zone: _ Outside Flood Zone? Public❑ Private 0 Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP1 2.1 Ownerl of Re rd: G ceA0t-,k aA,>,;la.I , .)n 4 Inay. nA. - ,-,,, ,A-r4Le MIA GDt'i`t Name(Print) City,State,ZIP 119.6\NIit ir) Rni .S-larrnou.h Li,ti) -}0Vt-1co1b cin•e_Abe 1 0.. \ e.t 1 chi\ iy No. and Street Telephone Email Address S�ECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction Cfj Existing Building 141' Owner-Occupied 0 Repairs(s) Er/ Alteration(s) 0 Addition 0 Demolition l Accessory Bldg. 0 Number of Units \ Other 0 Specify: Brief Description of Proposed Work2: Y'Q modem( (i-sc I ci ct. ••• - " •a . SECTION 4: ESTIMATED CONSTRUCTION COSTS JAN 2 4 7012 Estimated Costs: _w_._. Item Official Use Only Butt DING DbPA 1 ME NT (Labor and Materials) _ __ _ _____ �` 1. Building Permit Fee:$\O Indicate he .,` - .;; • 1.Building $ ;..0 'J' J tl,. A �9 Standard City/Town Application Fee ` 2.Electrical $ J � ou? J 0 Total Project Cost'(Item 6)viniltiplier x 3.Plumbing $ (0 C) 0, a j 2. Other Fees: $ % v1 1,Dk— 4.Mechanical (HVAC) $ 3 0 d J, J List: 5.Mechanical (Fire $ Total All Fees:$ 1 Suppression) `,, / �'1c0:;O Check No. Check Amount: Cash • 8.punt:� IX 6.Total Project Cost: 0 Paid in Full 0 Outstanding Balance Du,: \\5 I SECTION 5: CONSTRUCTION SERVICES '5.1 Construction Supervisor License(CSL) Ci- Y l et r I e V/1.7 7.,e, I 1 Q License Number Expiratio Date Name of CSL Holder List CSL Type(see below) V U I= a A S . No.and Street Type Description �m � G L i �� U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 11�2 I Z SSSI S Yer 17 on-nZt" I Insulation J J Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Chan les� d2zellc� r �► 2.GC� 3jt-► � _ HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name \bash No. and Street Email address arse\-,cam rY1'R 021 XU City/Town, State,ZIP Telephone SECTION 6: WORKERS' COMPENSATION ENSURANCE 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 Char`e j V o Z2,€ I c� to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electron4c Sign Lure) Date • SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of peijury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. QC-u\cry- N4: 156n 1 l �d Print Owner's or Authorize Agent's Name(Electronic Signature) ate 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.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" - , .N The Commonwealth of Massachusetts 2? ir l ,, Department of Industrial Accidents 1 Congress Street, Suite 100 'Q� Boston, MA 02114-2017 ;J 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): C If-ti( le 5 V 2.7.e I tc Address: 10 Gt 5-r S-- - • City/State/Zip: lip ham---) Phone #: Col-1 - i a--5c6 I Are you an employer?Check the appropriate box: Type of project(required): I.E I am a employer with employees(full and/or part-time).* 7. New construction 2. 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.]I 9 Demolition 4I 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.X Electrical repairs or additions proprietors with no employees. 5.0 I a a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'[ Plumbing repairs or additions m These sub-contractors have employees and have workers'comp. insurance.t 13.[]Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. 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 $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certij under the pains and penalties of perjury that the information provided above is true and correct. Signature: k, / a-2 Z c44 yyz._ Date. ?/ / Phone#: C (0 /7 9y7` r� 7 � Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: o� YA, �� TOWN OF YARMOUTH 211, BUILDING DEPARTMENT �'� nATTAGnCL�SFj.�xo� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA 1'h: JOB LOCATION: 4q PJ \N \ oim h cy . NAME STREET ADDRSS SECTION OF TOWN "HOMFOWNER" cAu\ Gc,ecfru, L L i 1 1 1-1-a-QA-1LD1to NAME HOME PHONE WORK PHONE PRESENT MAILNG ADDRESS Li � / ,u r-) r RVe, pj rn 1)41 . c\ U 2 l$L CITY OR TOWN STA 1E 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 foim acceptable to the building official,that he/she shall be responsible for all such work perfoiiiied 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 �J�10i-2? 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 �- ot'Y44 TOWN OF YARMOUTH ' %-' BUILDING DEPARTMENT 0A ! • H, 1146 Route 28,South Yarmouth,MA 02664 '•-__��,,,�,,3 ra,;' 508-398-2231 ext. 1261 Fax 508-398-0836 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 9 1.7> Vki A c ,r e Work Address Is to be disposed of at the following location: \ LyiN WaS*€. Svc 5o Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 11 ) )q / 9-1 Signature of Application Date Permit No. RECEIVED ° -: TOWN OF YARMOU'I"H I DEC 2 9 2021 �: : a BUILDING DEPARTMENT 1� BUILDING DEPARTMENT °� R- - 1146 Route 28, South Yarmouth, MA 02664 \/ JBy �� MATTA '+ Sty�°.Mnrtr /� A�'J°, ,�; Telephone 508-398-2231 ext. 1261. Fax 508-398-0836 Contractor's Affidavit: Substantial Improvement or Repair of Substantial Damage Property Address: / 1( 1 /, Airy iry Parcel ID Number: Owner's Name: AK,,,,,7 /4 4.//i Adk4) 4/645-p/ Contractor: /j Contractor's License Number: Go 0 / '/ (0 Date of Contractor's Estimate: I hereby attest that I have personally inspected the building located at the above-referenced address by the nature and extent of the work requested by the owner, including all improvements, rehabilitation, ,remodeling, repairs, additions, and any other form of improvement. At the request of the owner, I have prepared a cost estimate for all of the improvement work requested by the owner and the cost estimate includes, at a minimum,the cost elements identified by the Town of Yarmouth that are appropriate for the nature of the work. if the work is repair of damage, I have prepared a cost estimate to repair the building to its pre-damage condition. I acknowledge that if, during the course of construction,the owner requests more work or modification of the work described in the application,that a revised cost estimate must be provided to the Town of Yarmouth, which will re-evaluate its comparison of the cost of work to the market value of the building to determine if the work is substantial improvement. Such re- evaluation may require revision of the permit and may require revision of the permit and may subject the property to additional requirements. I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals that I have made or authorized repairs or improvements that if inspection of the property reveals that I have made or authorized repairs or improvements that were not included in the description of work and the cost estimate for that work that wer asis or i suance of a permit. Contractor's Signature Date: /0/--,/ 941 Notarized: / ' / AUTUMN L.BANKS a fc-- 02 0 / , Notary Public �� ` u Massachusetts My Commission Expires Aug 23,2024 t ' oR TOWN OF YARMOUTH _'! \`-`i BUILDING DEPARTMENT u 0 7.11 „ .:T 1146 Route 28, South Yarmouth, MA 02664 w Telephone 508-398-2231 ext. 1261 Fax 508-398-0836 Owner's Affidavit: Substantial Improvement or Repair of Substantial Damage ' i Property Address: 1 C/ �i I CI GI Parcel ID Number: Owner's Name: (j r.P�o r9 Pau .lc: kki Owner's Address/Phone: I B C:u rrcxr Ye.ki�} ZI /Sy Contractor: C h \f v c'2—:7 0, 1 \ OL Contractor's License Number: C S 04 4 3. Date of contractor's Estimate: I hereby attest that the description included in the permit application for work on the existing building all improvements, rehabilitation, remodeling, repairs, additions, and other forms of improvement. I further attest that I requested the above-identified contractor to prepare a cost estimate for all of the work, including the contractor's overhead and profit. I acknowledge that if, during the course of construction, I decided to add more work or to modify the work described, that the Town of Yarmouth will re-evaluate its comparison of the cost of work to the market value of the building to determine if the work is substantial improvement. Such re- evaluation may require revision of the permit and may subject the property to additional requirements. I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals that I have or authorized repairs or improvements that were not included in the description of work, and the cost estimate for that work that were basis for issuance of a permit. 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