HomeMy WebLinkAboutBLDR-23-9995 (2) s 1-7'f7'3
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ONE&TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department -'of r ._ p /cl�l / S
1146 Route 28,South Yarmouth,MA 02664-4492 t.
508-398-2231 ext. 1261 Fax 508-398-0836 w!iM`
Massachusetts State Building Code,780 CMR S I)c I Z J
Building Permit Application To Construct,Repair,Renovate Or Demolish
a One-or Two-Family e in'
Pu.�R-23—c4
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This Section For Official Use Only
Building Permit Number: 13 U) 23_ei517,513ate Applied:
1 l 1v, SQAcj ✓ S -)Ck-4)
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1. r erty ddress: 1.2 As'esprs Map&Parcel Nu3rrber
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1. of gcInformation: 1.4Property Dimensions: l O ` G o
9
Zoning District Propose t'se Lot Ares(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
0 `iii 0yS/7 a 0 (O `i
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informs n: 1.8 Sewage Disposal System:
Zone: _ Outside Flood ne?
Public Private 0 Check if ye Municipal 0 On site disposal system
SECTION 2: PROPERT 0 NERSBIP1
2.1 Owner'of Record:
tQ i 0-16; .rd �Sbc irk )/. .(4'16 Ci\ ( 111�r Ci ;�
N e(Print) City,State,ZIP
3 L4-4 e C el d t( . soe -737,5 y 57 Gem$� e. (—.t shc(vj (I2 SY 5(cl r (u
No.and Street Telephone Email Ad r
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction Existing Building❑ Owner-Occupied 0 I Repairs(s) ❑ Alteration(s)
0 Addition 0
Demolition U Accessory Bldg.0 Number of Units 1 Other X Specify: LASL C.k
Brief Description of Proposed Work2: r
f�Li,lcl Git X �Li Jec\s c4jcAce,F
.16 rc:.0 l.
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials) .
1.Building $ ti`) Occ I. Building Permit Fee:$10 t Indicate how fee is determined:
2.Electrical $ / 0 Standard City/Town Application Fee
0 Total Project C9et3(It _6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ • . . .
Suppression) Total All Fees:$ i ka-T,11,
Check No. Check Amount: Cash Amo t• cs0,6_,,,,,
6.Total Project Cost: $ 01 v 6 G.. ❑Paid in Full II Outstanding Balance Due:
rR
APR 20 2023
Bay _UI—LDING DEPA— RT T
SECTION 5: CONSTRUCTION SERVICES
5.1 ,Construc
tion Supervisor License(CSL) .70376 3 - 1 5-
(-JO/1Q, i \6 c/2. J C r CLi'cennseeNumber Expiration Date
Name of CSAder
e. '!J List CSL Type(see below) (...,
r.-.l ( l,' 1 c,i4
No.and Street Type Description
)( r/l'")6 v)-41 3 C !( C` /7G6 ' 1„ U Unrestricted(Buildings up to 35,000 cu.R)
1' R Restricted l&2 Family Dwelling
City/Town,State,ZIP Iv1 Masonry
RC I Roofing Covering
• WS Window and Siding
S0' Z 3 7 / 7 SF Solid Fuel Burning Appliances
7 I Insulation _
Telephone Email address D Demolition
5.2p Registered Home Improvement Contractor(HIC)
.-.I(Mh,,,, '',�' ( Ct,^ r7/e HIC Registration Number Expiration Date
(HiC C mpany Name or HIC Re istr t Name
Cnk i p l �•s: �u �3?�/ �
Q.an get Email add am
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 de - f the Issuance of the building permit.
Signed Affidavit Attached? Yes11 x No
. SECTION OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize -•1 Ci(1 c.i !1 C'
to act on my behalf,in all matters relative to work authorized by this building pertttit application.
R cc_k ko- 44—/6 3
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.
<- 10(A Cr eN e� "7/—/ — . 3
Print Owner's or Authorized AS 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 IIIC 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
=ate
r .Department of Industrial Accidents
v f I Congress Street,Suite 100
w'' _ Boston,MA 02114-2017
, ,. www.mass.gov/dig
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): -46l'1 <-6:r e a T i' jet Id Qp (r -� 1 (AL. 1 C
Address: 7` t`t'�r\Cnc,� i-v �l --3
Ca 6 7S'
City/State/Zip: k('rI'lc.J , p 1►' IC Phone#: SG F 73 7 /1 ' 7
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑i am a employer with employees(full and/or part-time).* 7. ❑New construction
2.Aam a sole proprietor or partnership and have no employees working for me in •
i 8.y capacity.[No workers'comp.insurance required.] Remodeling❑
3. 1 am a homeowner doingall work myself. t 9. ❑Demolition
❑ y [No workers'comp.insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on mYP ropertY 1 will t 0 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
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These subcontractors have employees and have workers'comp.insurance.t 1..❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c, I4., Other(' (�L� t dc
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 ant 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 c rtify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: `Y (6
Phone#: 6-6 73 /7 if G 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#:
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§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 ate 7� L U k P " cod I d d
Work Address
Is to be disposed of oat the following location: `6 J L i 55 L C1
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
q 16 cl
Si ture of Ap ication Date
Permit No.
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THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs 8 Business Regulation
HOME IMPROVEMENTCONTRACTOR expiration
Registration valid for individual use only before the
C expiration date. If found return tac
Q4 ., • Office of Consumer Affairs and Business Regulation
EARkligeg 1000 Washington Street .Suite 710
201342 .04/01 25 Boston,MA 02118
JON CARPENTER BUILf,31NO RE QOELUNG,LLC.
8
JOPINATHANNNACLE CARPENTERLANE
YARMOUTH PORT,MA 0287S
Undersecretary
Not valid witho t signature
lirDivision of Occupational Licensure
Board of Building Regulations and Standards
Constoltiiton tsrvisor
CS-070396 Mires: 03/10/2025
JONATHAN CA r �
8 PINNACLE /1f
8 PINNACLE` k141 y �
YARMOUTH PQRIlf •
1. 'c`
Commissioner clas bi miLea
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O4.y TOWN or Y.ARMO11T1 1
t 2v°c WATER DEPARTMENT
a, t_ 1y-o,4 99 Buck Island Road
le::,:; r.r' '�' West Yarmouth.MA 026'3
cgii '".'".g Tdophone -i0ti T.792 i • Fav `i418. 771-998
BUILDING PERMIT APPLICATION FOR
WATER DEPARTMENT SIGN OFF
TRANSMITTAL FORM
BUILDING SITE LOCATION: : ss
Z
PROPOSED WORK: b,„,,,\4 q x a.,y d,e,„;K:: et litcrjsa_a_klk IV v\Q a-r-
ecro ( •
APPLICANT: �Qh C ie _.�..w.. ..
ADDRESS: S' P,=a.rl�C le 1 o YGisv -,,ov.PtiocirIc P4r O 67.5
TELPHONE: 56 r 7 32 _!( a
RESIDENTIAL AND OR COMMERCIAL BUILDING
water I)eptrtment: Determines Compliance of Water Availability and or existing location
Fti inecrine Department: Determines Compliance for Parking and Drainage
Conservation Commission: Determines Compliance to'Wetlands Act: i.e If lot(s)border any type of
wetlands.streams,ponds,risers.oceans.bogs.boys,marshland.ETC...
I With Department, Determines Compliance to State and'town Regulations,i.e.
requirements for Septage Disposal and other Public Health Activites
Fire I)epanment: Determines Compliance to State and Town Requirements for Personal
Safely,Property Protections,i.e.Smoke Detectors,Sprinkler Systems.etc
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I�I.ECANT SIG'1>tTURF. I):1TE
OF CE USE:COMMENTS ON PERMIT APPROVAL OR DENIAL
REVIEW ;D 6n.VATER DIVISION(SIGNATURE) DATE
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ooY. A TOWN OF YARMOUTH
° HEALTH DEPARTMENT
'', PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: .
Building Site Location: G•Jiti `
Proposed Improvement: , \d )( D'y (-3ercix..5 SQC c 1-44 c.1i io IACQSQ
tjaVecr fri ems(
Applicant:PP C0f ezpite t Tel.No.:cj r 7 37 //c 7
Address: get.„,1 GC t P t 6 roQ ?la/set/1(i%) h e^T l /no. G 7r Date Filed: If-)<9.-) 3
**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: ‘ ,..c% 6 v4!
Owner Address: S 3 l 1,`,l,I t 'Kcj yo-r�a,J)i, , /V). Owner Tel.No.: g 737 5�y`7
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
„ ,} u Please submit three (3) copies of plans, to include:
� �ur(1�1Ch? (1.) Site Plan showing existing buildings,water line location,
�� AD � and septic system location;
(2.) Floor plan labeling ALL rooms within building
HEALTH DEPT. (all existing and proposed)-
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY,:, czy,,,oSCL,,,41---.....--' DATE: -/c-ot
PLEASE NOTE
COMMENTS/CONDITIONS: O*__ 7E-
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YARNOL/TN MA. 02664 14 =_