HomeMy WebLinkAboutBLD-23-004417 's
ONE & TWO FAMILY ONLY- BUIDING 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: �,�j.. `I� ] Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION "y
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 I 1.11)0 e,y- L.c1.• e-
1.1 a Is this an accepted street?yes no Map Number Parcel Number FEB 0 9 2023
1.3 Zoning Information 's 1.4 Property Dimensions:
eBUILDING DEDARTMENT
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 Zon
Check if yes Municipal 0 On site disposal system M
SECTION 2: PROPERTY OWNERSHIP'
21 1 w er'of Record:
.S h dY Name(Print cv. \A I yvi e� A-1 4 6aC.5
City,Stat ,ZIP
g r ►v,V t,i,v.e ,,SozT6/15�S
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) % Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units I Other Cl Specify:
Brief Description of Proposed Work2: c :rO 1 1.n
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: i". �a
(Labor and Materials) Official Use Only . \
1.Building $ 1. Building Permit Fee:$15 0 Indicate how -
� �tet�ined:�®`��J
2.Electrical $ Standard City/Town Application Fee _�'' Q�
❑Total Project Costa(Item 6)x multiplier ���f
3.Plumbing $ Q•
2. Other Fees: $ ;3 S ' 4 -
4. Mechanical (HVAC) $ List: i� 1
5.Mechanical (Fire c ,\\\.- 5
Suppression) $ Total All Fees:$ ... "� 0
� gh;cNo.k Check Amount: Cash
6.Total Project Cost: $ ' mat. �r
aid in Full O9 Outstanding Balance ue: I j
aII`lla3
'M SECTION 5: CONSTRUeTION SERVICES
5.1 Construction Supervisor License(CSL)
a L41,39 ? << I,Ze zq
l 'E xl i h f. License Number Expiration Date
Name of CSL Holder
i tgty 1,\o�e..vs,-, e)`( \ • e Description
List CSL Type(see below)
No.and Street K �C T
44
/� ,/� / Cu) Unrestricted(Buildings up to 35,000 Cu.ft.)
J 4e vvt0 tk 9 (Sy' 1� t o3b
City/Town,State,ZIP l R Restricted 1 Pu2 Family Dwelling
NI Masonry
•
RC Roofing Covering
WS Window and Siding
4- SF Solid Fuel Burning Appliances
6c S iolzO 16069- ,,r,eco w05&• nE I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) t
,.st n �ti vJ— 1<S 319 tp t t 1; ,t,�
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street <CAAke
ctvAA .E. Email address
City/Town, State, 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 %E" 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 'EUJ i‘. c;,,,„;t'
to act on my behalf,in all matters relative to work authorized by this building permit application. i
44 ito,437
Print Owner's ame(Electrons Signature)
Date
• SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering.my name below,I hereby attest under the pains and penalties of peijuiy that all of the information
contained in this
application is true and accurate to the best of my knowledge and understanding.
Ve.vin t--a,t{' Zlsr` Lv '73
Print 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.eov/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.)
Number of fireplaces Habitable room count
Number of bathrooms Number of bedrooms
Type of heating system Number of half/baths
Type of cooling system Number of decks/porches
Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
i r Department of Industrial Accidents
A 1 Congress Street, Suite 100
i i1r Boston, MA 02114-2017
www.mass.gov/dia
\\orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
�/ PIease Print Legibly
Name (Business/Organization/Individual): K�.
Address: 06, e'te
City/State/Zip: dl'n�0� 44r4 o Phone #: ®3 ?Lcq U�&7
Are youemployer?an Check the appropriate box:
(. I am a employer with Type of project (required):
❑ employees(full and/or
2 am a sole proprietor or partnership and have no employees working for me in 7. U New Jelin construction
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
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 n Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 11.[ Electrical repairs or additions
Plum
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Roof r rig 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.❑Other
152,§1(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.
I.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a 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: ,t-pLV 1.,e0
Policy#or Self-ins.Lic.#: /140.Z
Expiration Date: a`
Job Site Address: a /ones/ f
City/SAttach a copy of the workers' compensation policy declaration page(showing the policybfn er and expiration�� ).
Failure to secure coverage as required under MGL c. 152, v expiration date).
to$1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of STOP WO1RK ORDER on punishable
d a fine of up p 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 certi untie e pains and penalties of perjury that the information provided bo e is true and correct.
Signature:
Date: 2 Sr' 23
Phone#: 72(0
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License 0-
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
508-398-223.1 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 g l "4"46ifSk S , fvv - rt.
Work Address
Is to be disposed of at the following location: de'v1 6v4 Ut 1
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
,-,
Z- r Zoa,
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 number(s) 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 retuned 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 pennits 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 02 1 1 4-20 1 7
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15
www.mass.gov/dig
Commonwealth of Massachusetts
/. Division of Occupational tic nsure
Board of Building R ulations and Standards ti
Constlisor
CS-094639 4 *_ pires:07/01/2024
KEVIN J FAI
100HOMER '• ,r` 1.4
YARMOUTHFR ' y
3�
4,61,Ldrlil'>>
Commissioner d U f;. U6.1oc
•
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer A Business Regulation
HOME IMPROV ONTRACTOR
R
KEVIN FAIR �e
KEVIN J.FAIR a .
100 HOMERSDOCK R 4 £s(r A ".
YARMOUTHPORT,MA +•
. Undersecretar
fit , TOWN OF YARMOUTH
•7T o HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
Building Site Location: 5 1 ç
Proposed Improvement: C.Va w (7 ), Is 1►".1�{ L F6 d,E cc 6 +
Applicant: G.�1�\N / Tel. No.: k. D 7'j q
Address: kCiG , �<- c.t Date Filed: z
**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: (Th i"i,�` j (Act
y
t
Owner Address: t 44,4/ Owner Tel. No.: _C-‘
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: a. L 1,,, � `
PLEASE NOTE
COMMENTS/CONDITIONS: