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HomeMy WebLinkAboutBLD-23-000707 1 pA81ZzJ2? 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 ..,': 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 Building Permit Number: 3 -ow '2Q7 Date Applied: SQfk S k-'/�- R r E Building Official(Print Name) ignature I V E D SECTION 1: SITE INFORMATION 1.1 Pro erty Address: �/ L 1.2 Assessors Map&Parcel Numbers 022 Sri/yaw A/C7 13Adok.4P K 7�f t t= Bias — 1.1a Is this an accepted street?yes no Map Number Parcel Num ray:_T DEPARTMENT 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❑ Private 0 Zone: — Outside Flood Zone? Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 ner'of Record: f -4-/ 6 u i 4 (Prin City,State,ZIP $Magi a 46k/ aQ0 943 fO°)3701Sirycia_se qftq,. .V& No.and Street Telephone Email 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 N mber of Unit? JI/i r 0 Specify: Bri Description of ropoa7d W rk2: u F 4.�,,,5 �pi hop O'v -�. k b SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) p 1. Building $ 1. Building Permit Fee: $ OCX) Indicate how fee is determined: 2.Electrical $ al Standard City/Town Application Fee '))1S 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ t*i List: r 4.Mechanical (I-iVAC) $ t0 0,f�� ('�,$1 )� 7(L' '�� 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash 6.Total Project Cost: $ oZ{ (�V a_, paid in Full 'I11 Outstanding Balance Due 5, v lci'v/ V SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) f L.. c z c- — 4166.1/6 .La Jaq Q.5 c R t L 4 License Number Expiration Date Name of CSL Holder List CSL Type(see below) v P S No.and Street � Type YP Description S � ��,Q. + t t \,� �j U Unrestricted(Buildings up to 35,000 cu. ft.) T 1 + R Restricted I&2 Family Dwelling City/Town,State, V M Masonry na-G RC Roofing Covering WS Window and Siding . 1 SF Solid Fuel Burning Appliances L.'Ce3�G W ViNAC. m-a,Do e I Insulation Telephone Email address ,.fit-‘,,,,, „ D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date �q 3 , a,,,,, "ST A P"1" �- No.and Srtreet \/✓1E3< L.e c a 3 r G Email address City/Town, S e,ZIP V� 5 a 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 W p to act on my behalf, ' matters relative to work authorized by this building permit application. Print Owner's N e(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.- 11 ►J cg/C3g/a©e).(9\ Print Owner's or Authorized Agent's e(Electronic 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.eov/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" The Commonwealth of Massachusetts II E, = Department of Industrial Accidents 1 ;";p_= 1 Congress Street, Suite 100 ;l f= Boston, MA 02114-2017 .: www.mass.gov/dia «Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): L.1.cA,vS Address: 1 q 4c _3 V n N Rc A.D City/State/Zip: cev.-fie QV-. 1-R Phone #: ,... c.)83,6(\s-- Q Are you an employer?Check the appropriate box: Type of project (required): L©lam a employer with a 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.]t 9. ❑ Demolition 4.❑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 11.0 Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions 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•❑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: �,_1 E e k.K Policy#or Self-ins.Lic.#: -\19 1A.k,33 gy u t7 Expiration Date: 1 cA a) q k Job Site Address: ) s et Ji N c:7 ''��(( Attach a copy of the workers' compensation policypo declaration page(showing the policy nmWrr and expiration date). P ) 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: tJo9Cs _ �..„,r-1.4 Date: cn/CA papa Phone#: ....s"d$ 36e .( ,I0 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#: 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 r( ,s P-riJ3►.) G ,D j� `Jc31:?,: e41-.0 Work Address Is to be disposed of at the following location: ZR ' U Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Q 7c)a)c),Ic) Signature of Applicant Date Permit No. 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 numbers) 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 WATER DEPARTMENT ` os Z y„ ! I BL ILDING PFRMI`r APPLICATION FOR W . E'ER DEPARTMENT SIGN OFF "I R 1NSI ITTAL FORNI Tit'III)I\(.iSIF I_OC:\IR)\: , ,$ '/VNJAin &OtelKjki 1111.44 �7v1-t I APPLICANT: LA)/ Ar1.1 ',1 rAA t f,4-4-c) ie 5� �it-25 9i i t tou.c), (crn -4" ri/ C IN.S - ' 4PAV,..S te4P/0401). com -774 17;2 ' ' 7)i ,„ III.11IONF� - 0 RI-SII)I.\ II.AI, ..AND OR (.O\1\I1'M 1.1I_ HI'IL.I)I\G ' 11 titer I)e tttn tt: I')cteminc,( cntlimcc of 1atc 1e il,h;; tA and sir('Ct.,;n':! 1C1,athla I:n,,!ntc'erirq! Department nt; Determines( omp1E nce for Parkin. and I)raiihrg (`++n,c-t‘anon Ginmussion. Ikic n mes Compliance to Wetland's \tit. i . If l{qts)border anti ttipc of tt et!Ands, stream,, ponds.ri'cr.i, Ot:eAal, I14,t!4, ht1)S, marshland: t' 1(. I teilth I).partnieut. I)eteFntune,Compliance to State find I cm n Rctlulation:_ i_c. requireiuellt, list`eptage I)i,peaaal and tether Puhlic I Icalth ;Acti>ile, 1.11 eI)epartnaent ()en:mimes(`ulnpliance to State and II.mn Ite:lutretnent. tor Personal Sa I . . Property Protections, i.e Smoke I3ttectar.. Sprinkler Sysf nt .cat .1PP1,IC;1N I SIGNATURE I)VIE °Et 1(`F_ t'SE: CO\11IF\F S ON PI, I R1II I ‘I) I PRO \I. OR 1)1 \11I i i RI 1 11.1 .D B1'1 °:11 E I)IV'ISIO\(SIGNATURE) t)1'1"F: , TOWN OF YARMOUTH ' J ' `SHEALTH DEPARTMENT 5 r PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed hj Applicant Building Site Location; 154ln"•v tit; C-7 4, -%X; \.71 It, I, e J f m i Proposed m iovernent: i ` li / , 1 ?- :,i l,X ..) ,,,�:, , .e. . -- Or ( 3 F,c - - _f c ,._ _ _ C/ 14 __..__ Applicant: \`I/4/4 C 1 j C t-•C i 4 C H 1� 1 0 r�l~ l � ' -- - .._._.__ Tel ��:.� � �` � �, � C� l t .. Ni Address: IL ✓` 4; - .1 f �.{ Date Filed. a ).7— L Z. "lf.you would like e-mail notification of.rIgn oil please prm ide e-mail( dress i Owner Name: t_t _ n t `�.% '�',,l,->t` .i j.- Owner Address: ,�)t t•t<: L ......'`2 L-c„^,'/�.-,i `t"'' L`' c,�?/-t 0\Vile; 1 e i NO t 2C- . f<, 4 c` RESIDENTIAL AND/OR COMMERCIAL BI'ILDING HEALTH DEPARTMF' 'l : Determines Compliance to State and Town n Rc ut.atuo7, . : t' . Require 3ienn:: For Septage Disposal and other Public f lealth Activitie, Please submit three (3) copies of plans, to include: (1.) Sie Plan showing existing buildings. water line location, and septic system location; (2.) Floor plan labeling ALL rooms '% ithin building (all existing and proposed) — A'ote: Poor plans not required fOr decks, sheds, windows, roofing; (3.) If necessary. Title 5 application signed by licensed installer with fee. REVIEWED BY• ..... -7 ,./ DATE: 2 — 7 -1- i' / PLI.ASE NOTE COMMENTS/CONDITIONS: .^.. . 0 lI(�( ")(- 11 t t `- ?` '"1' a C c_wt ,:..' 'j-- `7 --c c;;r' _ ��71.-i t_ �t ot.r,�,r TOWN OF YARMOUTH •4 HEALTH DEPARTMENT '�•`` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: �,, / Building Site Location: ) Sir n/N fN 7 Z J o""k'.1H j 14,14 0 J1I{ Proposed ov Im em t:; I 1 (r) 2./ / / N ti 2- l N 4(t* J i`s'°,\J S 1)Y-, C ff N v or `Ff? ,34ti4- Pi/40- o �G � N-� Applicant: A (A C I PC et t 2 A p"C i-f (l 0i s Tel. No.: 5-0 e ) 6 () cl I 0 Address: '9 V / e4�,0 .5-1 t)ln1 Sou Date Filed: 7�7-2 - Z' **Ifyou would like e-mail notification of sign off please provide e-mail a dress: Owner Name: Of f N,v 4 (- Owner Address: _? E.5 A Air ti (--) i}/-40--A. doky I') l/v'./'1W'N Owner Tel. No.: (2-14'3 )143 4, 3--).3e L 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. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (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: .� DATE: 2 1^?—�+ . PLEASE NOTE COMMENTS/CONDITIONS: (( (- D 0 //)c (._ 47 c A-e_ Pu p_c `� c t Su ti ` '" "( OV PJ S '11-( L. '74 hf' } sue ` �'Y. `F . sus $' " �h� .tom. - t- �5. $ ti 1.: .. ..., /Wi £% ,"'-" t �-'4 Y'f .� '�' ::At,.-_,,: sue'.. 1 -` / _ �...�--'9l'._ d`w. 3> riot " d a ' c... _ _ ,,.y sit fi } - _ Zi • t' YT3 Lie.. -'if�✓�-n. • R 4 1. C; m r .r • xgA • 4 4 Or WATER DEPARTMENT c, MAIMING PERMIT .APPLICATION FOR 11":A"1'}:R DEPARTMENT SIGN OFF TR-A\ti1ILTFA1. FORM RI l)I\(.i SITE LOCATION: A/C7 ' ..5QV I ' , n s E'rZt)P()�;I;I) WORK: y� v K f '1 , 44- a,, APPI.IC`ANT; 4l :., /- �..>'l�r 4,r�' t c-13 :\DURESS: / 1.- 1 6tr`,t t JC' ?> apJ j ,. ,) , t I fb e ) ., ., I Fi.PI IOyEt c1 I 0 _ ,.. 1 RFSII)FIN I_AI. AND OR ('OyI\IFR( I:AI. E31'!LI)ING Water I)e atiment: I)oommes Co(nphan,:e of Witter livaddhilii) and sir e,Atstt€g location fsigincering Department. I)eierminc,('nntphatt,.. for E'arkiue aiid Drainage ( onset lanon Commission. I)ctc}navies(`u0tlptau..c to Wetland :'1et: i c If 101(w)horde!' and tulle cal V.etlands. NIreanFS_ ponds,ri crt, ocean, hot.;,,. 1hi4n, i •r',hIanil, I"r(�. Ilcuith Deportment: I)etetitiines( ninlance to State and I mA n Regulations. i.e. requirement, tier Sept age Disposal and other Public I lea!th Aetit ices I-ire I)partiti ilt: I)elermines Compliance to State and limn n Requirements for Personal Stticik, Property Protections, i.e Smoke I)etcclors, Sprinkler Systems,ete ,APPI.IC:AVT SIGNATURE RE`: I)\.I,F OH-I(`F: USE: COMMENTS ON PFR\1I 1 11'1'16)\ '.l O1! I)1 yI \I. „ r _ ` ' G R}:1'1}.1 .1) ESN 1 'A ER DIVISION (SIGNATURE)71 ‘11411 / zi,I)1"I"}: Mk • ONE or TWO FAMILY- BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: i L 0 (3 r,L ir Scope of Proposed Work: iZ 4 u c��) •_ , (J� `y� Date: Q (n412c,�_,I Based on the scope of work described above, the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept. -508-398-2231 ext. 1241 Conservation -508-398-2231 ext. 1288 / Water Dept. -99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. -508-398-22631 ext. 1292 Engineering Dept.- 508-398-2231 ext. 1250 Fire Dept.- Kevin Huck/Matt Bearse, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement: J C-� /C /c: a ! Signature pp g Date Rev. March 2022 FG e 7- /3-,./,' tifit, 8607-21 NAME Diana 4 Behnke 5-21-92 STREET VILLAGE SERVICE NO. -- ---, r METER NO.NO. .'/1" / g.4_,31L-W . ! • i I 1 . \ if:/ / / \ . 11:t 50 ty2?P.it \ \ • \ , \ ' • \ • \ : • s. . • /1..— t,1 i •I ••,'1 \\11 • . . ..,—7...— ... . . Lions home improvement 1949 falmouth road Centerville, MA 02632 ✓� /JC/JZIJLI>C!/JPO��/%iLll�l././(,!!^)P.��i 'Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 201015 02/22/2023 WALACI PEREIRA MACHADO WALACI MACHADO- 193 CAMP ST APT J-5 a 'ti -% WEST YARMOUTH,MA 02673 Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Not valid without signature • "S . Commonwealth of Massachusetts 11:1 Division of Occupational Licensure Board of Building Regulations and Standards Const*It+on Suppervlsor CS-116646 6cpires: 12/29.'2025 es, WALACI P 1‘,4#CHADO 193 CAMP ST; APT J5 WEST YARM6bTH MA 02673 I I IA I. Commissioner •-.-Xthig f . ?fie..04(1,"_