HomeMy WebLinkAboutBLD-23-001579 '4' piA co3Oize__
ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department ;:•••' "1;*-
1146 Route 28, South Yarmouth, MA 02664-4492
h 1
508-398-2231 ext. 1261 Fax 508-398-083b �,
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: b. Lo 23-t , Date Applied: "
Building Official(Print Name) azure Date
SECTION 1: SITE INFORMATION LSEP 2 3 2022
1.1 Property Address: ` 1.2 Assessors Map&Parcel Numbers BUILDING L - j1
Number Parcel Number
1.1 a Is this an accept d street?yes no Map -- —- _
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 El
Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system
SECTION 2: PROPERTY OWNERSHIP'
221-G�Scn�r'off V ecOt l aS tv, 'kr i!"o G{�I, M1'1n
�
Name(Print) e City,-
i State ZIP 1
tU i>) L 3t*-91b-133k
No.and treet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'"(check all that apply) ,
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Of Addition ❑
Demolition ❑ 9A�ccessory Bldg. 0 Number of Units Other .0 Specify:
B rii.Desc ip�tio S f I d r d Alork2:
, J y, lib i- 14� &A. rev, 0--aft,
l e 1 .�g1! , cL`
a S Le < n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) � s.--Official Use Only
1.Building $ a3 last) .-° 1. Building Permit Fee:$- A _Indicate how fee is determined:
2.Electrical $ Standard City/Town Application Fee
id Total Project Cost3(Item 6 x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: c, In
�'
(t
5.Mechanical (Fire L 1(fi
Suppression) $ Total All Fees:$ 1'
Check No. Check Amount: Cash Amount: 5
6.Total Project Cost: $2.3 en ,. ❑Paid in Full iiOutstanding Balance D «..:
1 et\e3bieZ;Z-
SECTION 5: CONSTRUCTION SERVICES
5. Constructio upervis/or License(CSL) e5-6/L/3 ((
W id6 1
eo r�J1 License Number Expiration Date
Name of CSL Holder J
)3ey st,o List CSL Type(see below)
No.and Street b Type Description
' j 6 h 4 /114 P 636 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
&69/111. lip��} ����J_� lSF SolidFuel Burning Appliances
7 1 I b bu, 11Q�� roilInsulationTehone Email address Demolition
5 Registered ifIpme Ir ove�nen�Contractor(HIC) j/g 5 N i /?i
Lego9 c w , e , U
HIC Registration Number Expiration Date
o y i e or HIC R is anname /
o. aand Stre t HA ` 3� C6 /1/1/ U�ki I Email a dress
Ajk
.,ity/Town, State, It)
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 Iss nce of the building permit.
Signed Affidavit Attached? Yes No 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR/ BUILDING PERMIT
n I, s Own of the subject property,hereby authorize �f eo r ..+ pL,Lte
t act on behalf, in all matters relative to work authorized b�this building perm' appli a ion.
• t Owner's N Electronic Signature) Date
• SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
l y ent : g my name below,I hereby attest under the pains and penalties of perjury that all of the information
couta' e in this application is true and accurate to the best of my knowledge and understan ng
4rmt 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.00v/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"
Commonwealth of Massachusetts
Division of Occupational Licensure
19 Board of Building R and Standards
Cons on*p3rvisor
CS-014344 fires:03120/2024
GEORt W*AM• X
130 LP O B €,3¢0
BARNSTABL1 MA 02630
4'61.1V.L
Commissioner issioner ♦ t /� Cmlba.
Address and Reium Card.
THE COMMONWEALTH OFMASSACHUSETTS
Office of Consumer Affaka&Ektsiness Regmlation Registration Yalid for Inidvidud use only before the
HOME NMPRO CONTRACTOR expirdion date. If found return to:
T Office of Consunur Affairs and Business Repdation
1000 Wasidngton Street -Suite Tt 0
104514 E8t1212024 8oston,MA 02118
GEORGE W.B1,AKELY`.. . .
GEORGE W.BL AKELY
130 REDWING LN ;
BARNSTABLE,MA 02630 umierseciebNy Not valid without s1 anus
E
The Commonwealth ofMassachuseixs
_ — Department oflndustrialAccldents
__ —,. • Office ofInvestigations
_ '�'—_ 600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
ADDlicant Information / Please Print Legibly
Name(Business/Organization/Individual): (1eor r '(/a i e L. (S91; /dam /
17
Address: 6 . ay ? o6/
City/State/Zi : ' rA5 6 4 t 1-61 6 ;®Phone#: (Cog. 36 ' 1/9 -7
Are you an employer?Check the appro to box: • Type of project(required): •
1.❑ I = .. a employer with 4. ❑ I am a general contractor and I
..ployees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction
2.P I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for mein any capacity. employees and have workers'
9. 0 Building addition
[No workers'comp.insurance comp.insurance.:ram,] 5. 0 We are a corporation and its10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself[No workers'comp. right of exemption per MGL 12.0Roof repairs insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.0Other
comp.insurance required.]
*Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they am doing all work and then him outside cofactors most submits 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for = . - coverage verification.
I do hereby certify under•AXIns and penaldes ofperjury that the information p is true and correct.
Signature: Datee....- %�.' / 4
Phone#: — ( 5 d� 3Cr� gg77
•
Official we 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#:
•
° • Aii TOWN OF YARMOUTH
firr• ,
o BUILDING DEPARTMENT
' _
\cc MATT 1� t �: 1146 Route 28, South Yarmouth,MA 02664
`= �•�.« Cd 508-398-2231 ext. 1261 Fax 508-398-0836
E :•
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 44 6 1 4( y i ( i A-9
Work Address
Is to be disposed of at the following location: L ,.
Ye) 1� �/ l�
Said disposa ite shall be a licensed solid waste facility as defined by M.G.L.
Chapte /, Section 150A.
014,2
//At
1���'fe o Application
Date
Permit No.
Manufacturing
� � ,LA p_ I ACKNOWLEDGEMENT
O o
Customer Quote Summary
BILL TO: SHIP TO:
LANSING HYANNIS MA LANSING HYANNIS MA 11111111311111111111111111
PO BOX 6649 186 BREEDS HILL RD
Barcode
HYANNIS MA 02601-1860
Phone: 804-266-8893 Fax: 8042616743 Phone: 508-775-7788 Fax:
QUOTE NBR CUST NBR CUSTOMER PO DATE CREA LED DATE ORDERED ORDER TYPE
5280778 1141346 1024166 3/21/2022 Quote Not Ordered Charge
ORDERED BY STATUS SHIP VIA DELIVERY AREA
George B None Whse Delivery LONDONDERRY MANUFACTURING
CLERK JOB NAME COUPON
dfs -David Silva 46 Doherty Lane SY-Blake
LINE# DESCRIPTION OTY UNIT PRICE EXTENDED
10000-1 Vinyl Patio Door,Unit Size 59 x 79.5,RO 59.5 x 80 1 $1,023.22 $1,023.22
Unit 1:U-Factor=0.29,SHGC=0.27,VT=0.51,HII-M-37-01086-
00001,Transactional Order Type=Charge Order,New Construction,
LEFT OPERATING FROM OUTSIDE=XOUnit 1 Left Glass, 1 Right '1
Glass:HII-M-37-01086-00001
Call Width=50,Call Height=68,Frame Width(Inches)=59,Frame
Height(Inches)=79.5
Double Glazed,Low E,Argon Filled,DSB,Tempered
Base Color=White
Flush Mount Deadbolt,Program=None,Label Name=Harvey,Dual _
Point Key Lock 59.
Fiberglass Mesh °_,ate
L-Fin,Inside Extension Jamb Receiver Pocket=No
Overall Frame Width(Inches)=59,Overall Frame Height(Inches)=79.5,
Overall Rough Opening Width(Inches)=59.5,Overall Rough Opening
Height(Inches)=80
Clear Opening Width=22.75,CIear Opening Height=75.875,Clear
Opening Square Footage=11.99
E.Star Zone:North=Yes,E.Star Zone:North-Central=Yes
Room Location: None Assigned
Last Update: 3/21/2022 4:06 PM Page 1 Of 2
Printed:3/21/2022 4:06 PM
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