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BLD-23-001107
pd ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department of r 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 ` , .;;,i. ' 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,2,3-,b t 1� Date Applied: tires 5ZA`5 91--)>4 RECEIVED Building Official(Print Name) • Si attire Date SECTION 1:SITE INFORMATION AUG 2 9 2022 Li Property Address: 1.2Assessors Map&Parcel Num burs .-r 13 i, s - ��redid- 1.�23;rois-' R.;.( , 7'i BUILDING DEPARTMENT 1.1a Is this an accepted street?yes)0 no Map Number Parcel Number uY. 1.3 Zoning Information: 1.4 Property Dimensions: O Liy , o- c SF IC t 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 73:, is q. a. ''d o cis N II— 1.6Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private 0 Zone: — he keif yeFloo d Zo Municipal 0 On site disposal system CI CSECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 'ir-let + Kr',.. +c r Ke if{.--� - t n..,J-t- 01/ -- 6 a- 6C9 Name(Print) City,State,ZIP /31,,res�- C ,d--l..tjteve-k Eel .�Zyr- ?5J=��i S cIc �l 'i �' �? (��,�c f �l�t— No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 _Existing Building❑ Owner-Occupied 0 I Repairs(s) 0 Alteration(s) 0 I Addition 0 Demolition © Accessory Bldg. 0 Number of Units Other IN.Specify: 'z,,rwne,J R..- c h Brief Description of Proposed Work2: c t`K 'Z 4 ,V--e4-4 Pu-'c L‘ de".,e '� SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) 1.BuiIding $ i S•, 06V t' 1. Building Permit Fee:$11;6 _Indicate how fee is determined: CI Standard City/Town Application Fee 2.Electrical $ )CNt A 3 ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ X 2. Other Fees: $ 4.Mechanical (HVAC) $ k List: te 0 Q 0 le! .�oZ 4?-'S ki ft_v;C\)s 5.Mechanical (Fire $ Suppression) Total All Fees:$ "t' Check No. Check Amount: Cash Am 6.Total Project Cost: $ (1- CP'-` El Paid in Full Ll Outstanding Balance Du : I't'�( \ 0 I e 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 1&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) f,( (Itv s702,1,?t HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date • I tr-e s* 6:e44-4-4>4 r,. p.1 S7 rt€t No( treet i"/-"'"' LMi c;.,)G 6�i �� 3 `vv L' 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 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 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: OWNER'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. J�vic e �� Print Owner's or Authorized Agent's Name(Electronic Signature) 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.5ov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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 cw• a • Department oflndustrial.Accidents 01= 1 Congress Street,Suite 100 it f.= Boston,MA 02114-2017 „� 4 www.mass.gov/diet Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information j Please Print Legibly Name (Business/Organization/Individual): +..}' "its Address: 1 " Le it- Gr.1- ram, Pd City/State/Zip: ,.,f�- --'�`k• 14/- 4 Phone#: ?� 7 G Are you an employer?Check the appropriate box: Type of project(required): l.Q 1 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.11 I am a sole proprietor or partnership and have no employees working for me in ca aci8. Remodeling an y p ty.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.(No workers'comp.insurance required.]t 9. El Demolition 4. am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 [1] Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E 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. 12.El 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. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box Al 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. 1 do hereby certify under the airs n penalties of perjury that the information provided above is true and correct. Signature: ��'� Date: 3 /aI Phone#: Y- -3 - 0 G 3 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#: ay � TOWN � ' YARMOUTH BUIlLDIN'� t° DEPARTMENT S";q r=�r 1146 Route 28, South Yarmouth,MA. 02664 508-398-2231 ext. 1261 j, cn »�fi. HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: in 4 kJ1v 13 s4 �-�2cf�1 " �t (el—At—`it c)‘c` NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" --5a i-1/4 k- co!`-2c)}r 6 re'6 S t r-q-y'--G Q C 1 NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TOWN STATE 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 G� 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. es No If you have ch cd_ease indicate the type coverage by checking the appropriate box. A . i ity x nsur nce polices' 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 ss. General Laws and that my signature on this permit application waives this requirement. Che one: Signature of Owner or Owner's Agent Agent h:homeownrlicexemp §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 at C l— + Cibw.�t- Work Address Is to be disposed of oat the following location: 1 -1-144" aziff Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 1-16-k- C/?k, /d S gnature of Application Date Permit No. ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE a� �na+f? 't Gi+ -y "� /�G Address of Proposed Work: � ' k4 k S. y°``"a'"'� Scope of Proposed Work: A �X 2 Y " r,ti.-ems RI--c'G, cis.cL Date: 67.3 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 onservation—508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Vold Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept.—508-398-2231 ext. 1250 Fire Dept.—Kevin Huck/Scott Smith, 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 Acknowledgemen • , 4 4- /,,?',// 4 Applicant's Signature Date Rev.Jan. 2019 Vi TVII Q'TVA 111'7 , `s'�s. il- s to ,,- csa c.a 2—' \ LOT 1 44,050 f S.F. T. , _, 1.all ± ACRES to Ql.. \ , in Co , , slettell ilk, PORCH Vig `. .. ) AA,4' ct? ZQ`6'i 0,.-- '', i51114 `'``9ARN' 1 `° EX 'r�1 DECK 40 b APPR©x. PUMP POOL HOUSE s-,' GREENHOUSE r-, • \ 0 0 " 5'; ' T)% 1/111 (71 16 7' tv SAS. LOCA 7EO aro-IA.46414 ,.![y.- �� TO 'LA (:.JT`:It ATIONsryS .— v,,:ag'+.1 ,<i 4-,`,. o' �s. , `�9`. ,J''°►i i ..a Y iltr...OX 'il • 4 RM * WATER DEPT DATE " * 1 1 ,. i" TO THE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN KNOWLEDGE, AND BELIEF THE YARMOUTH, MASS. STRUCTURES SHOWN ON THIS PLAN LOT 1,PL. BK. 576/18 HAS BEEN LOCATED ON THE GROUND DATE 3/4/2022 SCALE 1" = 40' AS INDICATED. JOB 6996-00 _ CLIENT KELLER 3/4/2022 `` _- SWEETSE.R ENGINEERING -," 203 SETUCKET ROAD DATE PROFESSIONAL LAND SURVEYOR PO BOX 713 SOUTH DENNIS, MA 02660 OFF. 508-385-8900 FAX. 508-385-6991 C. 1 S8 1 PROD 1 6996-00 i dwg I 6996-PPP-POOLI.dwg 0 2022 SWEETSER ENG. . . sEx+vicE NO. ! GX"t f - i 9 NAME STREEr l-3_ _it/es ,A,,c 41z VILLAGE 9, .. METER NO. 5.33 '�•,201F" 4 3 g lei/0 sts Pole ft "f 7 fc e p�y, ik TOkt"`. OF VAR-tit;)1,11# WATER DEPARTMENT C- ` "3 9) Buck 1)Iand R.k itt vAt t larnmoc,rtl1 t tt ( 3 hi 1t 1101'-1 _ _ 1._9 l t,tti. F'itft. , 1•?'r91i BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OFF TRANSMITTAL FORM BUILDING SITE LOCATION: ) t(t— Pc( 5' PROPOSED WORK: g").c' � R'sePler3 APPLICANT: e/v1,1, I'r✓A tte -- AL)DItI:SS: `44' 'I�EiL1'110NE; �`r- ?-? ^G)O6 RESIDENTIAL AND 'OR CO1+1MERC'IALBUILDING Witter E)epartmenl: I)c:tcrttuncs C'ompltance oflt'ater ltalla bility and or existing location }:nginccring i)epannient: I)etcrrnines t'ontplimice for Parking and I)r:tinav�c C'ctnservatiott Commission: I)cterinitte;Compliance to tt'etlands ,tct i.e. It*lofts)border any type of ee etl:tnds.streams.ponds.rivers.ocean.bogs.boys,marshland.ETC... I lealtIL t)eparttnettt: I)etcrmiacs Compliance to State and`1'(ttwn Regulatins. i.e. requirements titr Septage Disposal and other Public Ilea/ill Actis itcs Fire I)ett,ultttcnl: I)ctertttincs t'ontpliance to State and Town Requirements for Personal Safety,Properly Protections,i.e.Smoke I)eteclors,Sprinkler Systers.etc , i/(1<les? ff AP .ICANT SIGNATURE DATE OFFICE USE:CONIMEN I'S ON PERMIT APPROVAL.OR 1)F NI.t1. REVIEWED BY WATER DIVISION(SIGNATURE) "�" DATE: I„ � J :#NOiLvoIlddy iffiliri;1. 7 7 0.7/Vh- :peu6G elet3 0Villir aRea s4 cl)Artritippc /�� --wt—. 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