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Home My WebLink AboutBLD-23-005726 1 I Off-& TWO FAMILY ONLY- BUILDING PERMIT RECEIVED Town of Yarmouth Building Department of 1146 Route 28, South Yarmouth,MA 02664-4492 ,s�' !� APR 121023 508-398-2231 ext. 1261 Fax 508-398-0836 tom ■ Massachusetts State Building Code, 780 CMR BuJ ng Permit Application To Construct, Repair, Renovate Or Demolish BUILDING DEPARTMENT a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: i Cb-23"bb '7 A 10 Date Applied: I;tv rqiC5 '7- tAlt-4-- Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted sea?yes V fy4CA Map Number Parcel Number 1.3 Zoning Information: L'ih 1 ( 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 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SEC ION 2: PROPERTY OWNERSHIP' . Owner' Re or Name(Pri t) City,State, P e 1 DAvve- 56'D-?1 4217 No.anstreet elep one Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check al hat apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) Alteration(s) 0 Addition 0 Demolition 0 I Accessory Bldg. 0 Number of Units / Other 0 Specify: Brief DescriptionA of Propose W° k2: N(� ' j 4- Sfr"' (r<,, ate ,�✓-- �rt v f`-` ✓" SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ ��l�n .`- 1. Building Permit Fee:$X S(7 Indicate how fee is dete • ;� c C� 19 Standard City/Town Application Fee t. 2.Electrical $ �, �' ❑Total Project Cost3(Item 6)x multiplier �� 0,13 3.Plumbing $ 2. Other Fees: $ C ' 3 E R 9, �. 4.Mechanical (HVAC) $ List: �Q PPR,(M�N Suppression)5. 1 (Fire $ Total All Fees:$ 6v��"�\�G i' Check No. Check Amount: Cash .I:• l a 6.Total Project Cost: $ 0 Paid in Full • Ij`Outstanding Balance Due: ) d is Slav t 'SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) O ITYR '2-,9 r—� W 3�e p�� t 4-T r7 D j License umber Expiration Date ame or CSL Holder eb &\ l— 23>• List CSL Type(see below) No.and Street V 7 Type Description '4I / —54k IP / //�1 _ U�j a...) Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/ wn,State, 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) i 1 1 r ��^�� HIC Company Name or I CReeistran� e HIC Registration I y{/,tuber Expiration Date No.and Street �s At.`o'�" �f -6 �e A-fD,r „ imA Email a ress City/Town, State,ZIP Y-� 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 LV 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 authoriz[%%,.�.Ui_VAI S� 0 7_ to act on my behalf, in all matters relative to work authorized by this building permit application. A- Print weer' ame lectronic 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. 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.) , 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 '� Department of Industrial Accidents an= =Am= 1 Congress Street, Suite 100 ,E_IT: Boston, MA 02114-2017 N.�..- www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �pPlease Print Legibly Name (Business/Organization/Individual) N tom, Al�f\ e!j<. L__ N d, .t R�v4LL Address: Ac) i ( 2 7 �Lv 'mil(yr J City/State/Zip: /''t 4 S k,,,4- .'2_ Y1- oz.iiir Phone #: Sd ? Cm 2—_ Are you an employer?Check the appropriate box: l � ' Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in ca aci 8. remodeling an y p ty.[Tio workers'comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]1. 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 1 1. Electrical repairs or additions proprietors with no employees. — 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. The sub-contractors have employees and have workers'comp. insurance.: 13• Roof repairs 6. a 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. t 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: .....-------7 Policy r or Self-ins.Lic.//: ��T 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 ir -rm ! enaltie f perjur that the ' ormation provided above is true and correct. Sienatu � Date: -- P —; t" (Y')2 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#: 1 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 V Wp- conducted at: C/U. (Work Address Is to be disposed of at the following location: 12Lk- Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signat a of Applicant Date Permit No. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affajs&Business Regulation HOME lMPROVEMENNCONTRACTOR 'AE licaivrdual., R-•' ction LAWRENCE M.NADZEIpie 6 •ems � �` LAWRENCE M.NADZ A - x. 2 POINT ROAD MASHPEE,MA 02649AY = Undersecretary Commonwealth of Massachusetts Division of Professional Licensure glif Board of Building Regulations and Standards ConstiNMMI6 (visor CS-040948 1 Spires:07/05/2023 LAWRENCE M N• ' '% ! i PO BOX 2337 n' MASHPEE MA..0 • t 0/S'74 u. it w Commissioner K. bj&L, • • • • Fallon, Rosa From: J DeMars <jdemars862@yahoo.com> Sent: Wednesday, April 12, 2023 12:25 PM To: Fallon, Rosa Subject: Building Permit Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Good afternoon, I am allowing Mike Nadzeika to pull building permits on my behalf for 60 broadway street, west yarmouth, unit 19. Thanks, Jessica Sent from Yahoo Mail on Android 1 7 r- \..) -11/4' ........-•'''' ----_________„. 1.''.--- ---------.. •c------......._ f\ . .....__, --..„..........„ 1...,, ,---............ * t -- . ....‘" ) - ------........................... 7 Cf rr.1 F-, in -,-- --..\- \ .:„...i...,„ c . .. . •••--P I '11- 1 1 -ri \ . J 3 -- 1 ) . <..7) c .• , t. I--f4i A 71 2 r-