HomeMy WebLinkAboutBLDR-23-12837 (2) - • ►'i r&TWO FAMILY ONLY- BUILDING PERMIT
R C E 1 Y 0 Town of Yarmouth Building Department of
l 1146 Route 28,South Yarmouth,MA 02664-4492
I JUL. 2 5 2923
508-398-2231 ext. 1261 Fax 508-398-0836 I'
Massachusetts State Building Code,780 CMR .
Lt3
C' _pAR rrgy n Permit Application To Construct, Repair, Renovate Or Demolish ;
y. _ j a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: --2:- 11 Date Applied-
.
1 5el)1c5 B.'_ 3 4 3
Building Official(Print Name) • Signature Date
SECTION 1:SITE INFORMATION .
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
T Air CAR,SOIV WAY
1.1 a Is this an accepted street?yes 1:/— no Map Number Parcel Number
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:
Zone: _ Outside Flood Zone? Municipal ElQn site disposal system 0
Public 0 Private 0 Check if yesa
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
C*Oti 5 P�7`-,4'06Xi/ Y/91t,0avT-O® /.I
Name(Print) City,State,ZIP / ci 1R'T. P4-7:3mf),,/
/r// 4/1ifrA0'/17 fife/v see- A 3'7- 02 T% VIC Cc. mid>�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) Ell Addition 0
Demolition C] Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: /C )' h'&N R47, � 7w3
RA-4/4✓''7"/6.4- — (6.
R4.k x/ 7�// i,/ ,00,0a4.,- A D " O i0 7j,.hi.
/✓'E pY eA�.}A 4 Y Loi r7-- ,4-9lJ.d1`A G0�-' ‹,'6,?.., --.x,.
SECTION 4:ESTIMATED CONSTRUCTION COSTS. .
Estimated Costs: Official Use Only
Item (Labor and Materials)
1.Building $ S P o li, 1. Building Permit Fee:$ *ISO .Indicate how fee is determined:
1 Standard City/Town Application Fee
2.Electrical $ S--a b t ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ as-d'0 2. Other Fees: $ ,jS C V. -73C11
4.Mechanical (HVAC) $ -- List:
5.Mechanical (Fire $ Total All Fees:$
Suppression) Check No. Check Amount Cash Amount:
6.Total Project Cost: $ 5 2/5-a a El Paid in Full It Outstanding Balance Due: II 1"-
t
' SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C5_o1-93-357 3- 7- a�
7 f OMA.S D., G OAR 1 C-I.I D License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
0 MA 1.LA F D L N-
No.and Street Type Description
!t /A RW) £ j M A O 2,G 43- U Unrestricted(Buildings up to 35,000 Cu.ft.)
7 (�/ R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
j SF Solid Fuel Burning Appliances
so$ 2 3 7"5 79-7 ed/1/ k t'5�3yiddo-d- I Insulation
Telephone mail address ,GPI D Demolition
5.2 Registered Home Improvement Contractor(HIC)
MVAIn.c &o,07A/ot.'-6 Hb�//y a-3�t.nt�
HIC Registration Number Expiration Date
BIC Company Name o HIC Registrant Name
G/ 41liA A./4/ tiDy):�j/�iWL/ r09/1.ars•
No.and Street ti Email address ,Ld-/,'7'
)1/20.1 /L.f/ /16',024,'fr SO?-.1,37-3 f/p')
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 0 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 TH d f A S G JAR/G L.
to act on my behalf,in all matters relative to workuthohoriized by this building permit application.
C"Q'S “ccn--SJt.: (>4- ' 2 i
Print Owner's Name Electronic Signature) Date
2
• 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.
.' -.2/—.A.3
Pr n Owner's or Authoriz 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.rnass.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"
§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 4/ T €A ?
Work Address
Is to be disposed of oat the following location: S a C .
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
Date
Signature of App ica on
Permit No.
The Commonwealth ofMasssachusetts
�' I Department of Industrial Accidents
1 Congress Street, Suite 100
, Boston,MA 02114-2017
,tir— www.mass.gov/dfa
~ Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): T G 0 TA E j /7"Hp 7,9- Gt)A.R )64 /e)
Address: 6 1s,1A lL. L.A RJD LA,ivE
City/State/Zip:PA Rom'/G{�/ M A e7,2 ►r-)-" Phone#: 3' 'f - 2 3 7- 3 r
Are you an employer?Check the appropriate box: Type of project(required):
IQ 1 am a employer with employees(full and/or part-time).* 7. Q New construction
3.0 I am a sole proprietor or partnership and have no employees working for me in 8. Erkeniodeling
any capacity.fNo workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10 Ei Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.[ (am a general contractor and I have hired the sub-contractors listed an the attached sheet 13 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6_0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 must also till 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 joh 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 pains and penalties of perjury that the information provided above is true and correct
Signature: Y Date: 7 ` 2/ 2 3
Phone#: ✓ b a 7 3
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License ii
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CityfTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#:
Contact Person:
TG HOMES-SUB-CONTRACTORS
WORKERS COMPENSATION INFORMATION
J
TG HOMES-Tom Guariglio N&M Excavating
General Contractor 1250 Long Pond Rd
Ace American Insurance Company Brewster, MA
6562UB-4 425P87-5-16 AIM Mutual Ins.Co
VWC 10060247022020A
Summit Insulation Scott Brazil
PO Box 1337;Harwich, MA 02645 Stairs
AIM Mutual Insurance Co PO Box 777;Truro,MA
VWC-100-6015914-2015A WCC5008740012009
Hutchinson Roofing-Michael Hutchinson American Waterproofing- Kenyon Keyes
PO Box 534; Brewster, MA 02631 133 Tonset Rd;Orleans, MA
AIM Mutual insurance Co #6608155
#VWC-100-6005898-2015A
Ryan Stevens-HVAC
Dick Bindig 184 Brook Trail; Brewster, MA
Pindig Plumbing&Heating Hartford insurance
PO Box 553;S.Orleans, MA 02662 08WECCQ1567
The Hartford Ins.Company
#WCOBWECRH3903 Mike Steinmetz-Painter
51 Boulder Road; Brewster, MA
Kikorian Hardwood Floors,Inc Travelers Indemnity
PO Box 1200;Brewster, MA UB3A59333
#08WECT1869
MAC Electric
Randy Clark-Clark's Drywall 102 North Westgate Rd; Harwich, MA
1780 Orleans Rd;Harwich, MA National Grange
Travelers ARWC W04224W
VWC-100-6020621 -
JM Madden Company
White Plumbing&Heating 15 Perry's Way
19 Skippers Drive Harwich,MA 02645
Harwich, MA Plumbing
Norfolk& Dedham Mutual WE216537A
WE156820A
All Cape Foundations
1125 Governor Prence Rd
Westco Insurance Co
WWC3130711
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building R uiations and Standards
Consstta TS rvisor
CS-049538 * Spires:03/07/2024
THOMAS D ,
6 MALLARD a' O loft
HARWICH Mtn 0
4iULLVdi:33
Commissioner dui
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration Expiration
101114 01/31/2024
THOMAS GUARIGLIO
THOMAS D.GUARIGLIO /
6 MALLARD LANE
HARWICH,MA 02645 Undersecretary
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