HomeMy WebLinkAboutBLD-23-001096 •
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ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department �oF
1146 Route 28, South Yarmouth, MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 rii
Massachusetts State Building Code, 780 CMR \o.....l�
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 3Lb--'Z3 dtttfv Date Applied:
6 --
iy J
I 1 r� ceA� gRECivFoI
Building Official(Print Name) S a e Date J
SECTION 1:SITE INFORMATION T AUG 25 2022
Li Pr perty Address 1.2 Assessors Map&Parcel Numbers
BUILDING DEPARTMENT
ow,jie
1.1 a Is this an accepted street?yes no Map Number Parcel Number ay
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) f
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 0 Private 0 Zone: Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
1 /& h �vd,.&, /rim° -po(/ , fA D024 2-1 -
e(Print) ty State,ZIP
10 9o'1 / a. 64- ((o1)9P/-DDO 6, 134.500d cO c na;1.ta h
No.and Street TelephoneEmail Addres4
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 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:
(1 Veil-4- teiS.eritu ck) r rl+D
✓ SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 3> f./0•ao 1• Building Permit Fee:$_KO Indicate how fee is determined:
2.Electrical $ v v� Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ /J v
4.Mechanical (HVAC) $ List: � �
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
t,76.Total Project Cost: $ l fir 00 0 Paid in Full a Outstanding Balance Due: 0
SECTION 5: CONSTRUCTION SERVICES
5.1 I .
Construction Supervisor License(CSL)
License Number Expiration Date
Nar;ie of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
V 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)
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No. and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(111.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 0
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.
&Keer,Cr fie,w,✓ AT,% _ S- LS- Lott
Print Owner's or Authorized Agent's Name(Ele nic 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.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"
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# Jik?do k,1•be 3.111401t
The Commonwealth of Massachusetts 0 \S
I 4— Department of Industrial Accidents (\
=L�1= 1 Congress Street, Suite 100 V
S715f Boston, MA 02119-2017
;�•'•� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
t - arne (Business/Organization/Individual): j' L'1e r. it h n( '3CO J,
Address: '
„--Eity/State/Zip: ((r /�� /�1��; ,9 )Phone #: ( tJ 7ii Q(�a
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.❑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.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
4. 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. 12.0Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.! 13• Roof repairs yt 6.0 We are a corporation and its officers have exercised their right of exemption per NIGL c. 14.{[/]"Other CQ/ly-[fA64ul�e//
152,§1(4),and we have no employees.[No workers'comp. insurance required.] affA� ,�L�r ,f �it/11��f1U►
*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:
t/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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: eaw
Dater
Phone#:
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#:
oi.YAit----,,L,;\
TOWN OF YARMOUTH
k _ -ti) BUILDING DEPARTMENT
TT,.�„«.E 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: "A SA --
JOB LOCATION: C o,o64./1 9d9&h ,21- %/f)1O 9/ 7
NAME STRE T ADDRESS SECTIO OF TOWN
"HOMEOWNER" a�i) `c )1/1 (SOS' CItP/�Del10 ( , "" 17- 2
NAME HO PHONE WORK ON �?y
PRESENT MAILING ADDRESS 9oY d_e U4 �� ii
442.-- !Kik.del j/f "it o 7
CITY O' 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. 6f..e.4.-
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a curre 'ability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. ( s No
If you have chec ed s, please indicate the type coverage by checking the appropriate box.
A Cliability insurance icy 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 Mass. General Laws and that my signature on this permit application waives this requirement.
e>-t-t^,(40 one:
Signature ofner or Owner's Agent cwne Agent
h:homeownrlicexemp
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 47Z,) /a)e/ A ymiAid A 71—
. 1Work Address
Is to be disposed of at the following location: ) /iiô&)h( /�/(�1 �;dG,,t'`K,
„,.s. fiiz,pdA &,ye.4
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
'.1?(Aliijr3L---- e.AC::: ::)--•
Signature of Applicant Date
Permit No.
r RECEIVED
ONE or TWO FAMILY— BULDING PERMIT AUG 25 2022
BUILDING DEP
APPLICATION REGULATORY APPROVALS NOTI ' By,r_ TMEN
0Cl 15O,llc)
Address of Proposed Work: ? �jijie A yr/i-vd 417/
Scope of Proposed Work: )/1l t // ,7L,14,n' €' I G✓,./ic //2 hi
Cal ii `"7 re s.. L41IA 1e.-z .
Date: if/AD
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—.SJp'n Md. d/aS/a3--
/Conservation —508-398-2231 ext. 1288
r/ Water Dept. —99 Buck Island Road, 508-771-792154?", &J _s7 i Z-
✓ Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292,40p/a'J-K�o/°14- 11-1ar41-ci.
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:
47
cv.,--/2,
Applicant's Signature Dat
Rev. March 2022
# ,c WATER DEPARTMENT
(s.
' v,
BUILDING; PERMIT APPLICATION FOR
WATER DEP:1RTMMENT SIGN OFF
TRANS'11ITTAL FOR11
BUILDING I_. ELOCATION:
904 Route 6A Yarmouth Port MA 02675
PROPC)SEI.) WORK: Convert basement window to an egress window.
Kristine Goodwin
APPI_.ICANT:
904 Route 6A Yarmouth Port MA 02675
ADDRESS:
(I [.PI{()N t : 508-981-0006
RESIE)I\11AL. \ND OR ('O\I\1I',RCIAE. BUILDING
Water Department: Determines Compliance of Water ,v.ailabilitti and or existing location
ltngincering I)eparttaent: Determines Compliance for Parking and Drainage
Consersanon Commission: Determines Compliance to Wetlands Act: r e It tons)border any type of
Wetlarmfs,streams,ponds,tilers.ocean. bogs.bus . marshland. F hC
I Iealth Department: Determines Compliance to State and Town Regulations. i.e.
requirements !Or Sewage Disposal and other Public !lath Actin ites
Fire I)epartment: Determines Compliance to State and'low n Requirements t r Personal
Safety, Properly Protections. i.c.Smoke Detectors.Sprinkler Systems.etc
X) , 8/25/2022
1PI 1Ni SIGNATURE I)1"CE:
OFT ICE: ESE: COMMENTS ON PE:R\II.i APPROVAL. OR DENT I.
f , /7,e- (r Vb e1/4,` -t'r- f`1r/Cam.c f-S f Nt. -t—A , t . r J 0 4c., 4-- ent 7—
,4 6 tt1<..t. 45 8 e.. Co e. x r-e 61 IA k s:v,_ic. ,,.r ,4-- �(yy
4,,,_ 4-4/...—' . 94,/..2 a___
12I:A IPA\ED BY RATER DIVISION(SIGNATURE) DATE
tO
:4 '''‘k' TOWN OF YARMOUT
'; 1.'6-4HEALTH DEPARTMENT RECEIVED
---
.., Sp �q
PERMIT APPLICATION SIGN OFF TRANSM AL WHE"ET2022
BUILDING DEPARTMENT
To he completed by Applicant: / BY:__ - —
Building Site Location: % V Z ) J/€ Cfl,/j 1 {�'de* /3,/
Proposed Improvement: '/1/...e/T -exits/7-h) fr. ,j,Qrr t /if7btc) /47 ay)
. 29 'e&s 1.v J/t do uJ .--- c ce_c c c t-+ • ,:`l-m ,Ft=( c
Applicant: Znice___ goo ite.},,., feAJl7/te atizal Tel. No.( O(6 9P-OC.CJ(C
Address: 94' /e0 -e.-44 ¼tr,nc - A/4-- Date Filed: <0.1/
**lf you would like e-mail notification of sign off, please provide e-mail address: yOod sap- dp a i /*am„
I
Owner Name: ,�rpex_ d- i✓i:J hr,w._ O DQI.v;
Owner Address: 90 9 6 Ale 64-`Gt///Ylc) A Owner Tel. No.: 0(0 12�3?J
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:
)I‹ Site Plan showing existing buildings, water line location,
RECEDED • and septic system location;
(2.) Floor plan labeling ALL rooms within building
D
(all existing and proposed) -
HEALT H DEPT. Note: Floor plans not required for decks, sheds, windows, roofing;
If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: (. 7, DATE: g
- -(AG, - )_. ._
„PLEASE NOTE
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... ..�. i TOWN OF YARMOUTH
RECEIV ;'' x ; �' 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
mow" Telephone(508) 398-2231 Ext. 1292-Fax(508)398-0836
Oj,D KINGS HIGHWAY HISTORIC DISTRICT COMMITTEE
rAfifv= urt-t
OL0 K►NG',S H►GHVVAY APPLICATION FOR
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Two or print lepibty:Address of proposed work 9 y / Jk &n ¼L .!. tMap/Lot# /143 y q
Om-legs) ,e ir'rth ILe. /-? � Ca.C.?C ((A'.'c-'i n ......._.. Phone# 0 9 1"('1'd C.7
All applications t st,be submitted by owner or accompanied by letter from owner approving submittal of application,
4t iiirig addraes: ,l Y l of k �>' Year taut!:<
Email , A b c/ 6)//) S'' /yja f f' (Q/r,Preferred notification method;,-_-, Phone L, Email e, tr.�
. ...
Agent/Contractor:. _ • �. . Phone#: ._._.� �._
Mailing Address
Email: Preferred notification method .............. Phone Email
Description of Proposed Work(Additional pages may be attached if necessary)
/
0f flocde _ hot' v ,b/e Ir-Otiir6'4-
Signed(Owner or agent); ---� Date.
•
;+ Owner/contractor/agent is aware that a permit may be required from the Budding Department.(Check other departments,also.)
i» This certificate is good for one year from approval date or upon dale of expiration of Building Permit,whichever date shalt be later.
Egr Qommittbe itse Ohl*:
oats v l i...... Approved __APPrnvedf l�r (_Denied
Amount 09. IA Reason for denial._ i 1� 1
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Revd by: L► 5. _-___- Y�r Ar:Qt t"f HIN Y
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