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HomeMy WebLinkAboutBLD-22-006703 /9 y . _ , , 4,/ ot., site,. visi+- R E C E 1 V k TWO FAMILY ONLY- BUILDING PERMIT MAY 1022 Town of Yarmouth Building Department '" 1146 Route 28, South Yarmouth,MA 02664-4492 5-' 508-398-2231 ext. 1261 Fax 508-398-083b •• B UILDINC ENT Massachusetts State Building Code, 780 CMR �g-Permit Application To Construct, Repair, Renovate Or Demolish _ a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: SLIb-22—Oily 703 Date Applied: It. 11- cFl i c �� 6 Building Official(Print Name) ignature Date 5T/i( SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 3 Sa s II *gt QDjg°9r iviN ifik 1.1 a Is this an accepted street?yes ✓ 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: 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',Qf Re :° ��� �� fanil RIlj �rPpl�v S. Y,�R,r� 0%669 Name(Print) City,State,ZIP I 1 g3 Sail II g I�RD , 332'R6 l iIi pp 1i /,Cre No.and Street Telephone Email AddresSJ 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 ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description,of Proposed Work2: Da moil to Met, , 1242:f &-t-"-�' Ov77,424' 42. ,ap,0i°12 t,/m,N ail - 14 f e Pill q / FN�Ps i m R.. I-K-re,Q.iok. trimr s w J o PS l ✓ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ J� 1. Building Permit Fee:$ o'll'' / 14q) Indicate how fee is determined: 2.Electrical $y� 0 Standard City/Town Application Fee I ire/2`oC 0 Total Project Costa(Item 6)�x multi her x 3.Plumbing $ 2. Other Fees: $ 3S CIq 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ 6.Total Project Cost: $^ 1� Check No. Check Amount: Cashrt:). �'�'p 0 Paid in Full 0 Outstanding Balance D �Q ((�� , 1lI 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) 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(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 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: OWNER1 OR AUTHORIZED AGENT DECLARATION B entering my name below,I hereby attest und: 4 - ./its and penalties of perjury that all of the information cy ontained in this application is true and accur. .. ,- . .,. 4"owledge and understanding. Print Owner's or Authorized Agent's Name( i�,l;.% .'ignature) 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.) garage,arage(including finished basement/attics,decks or h Gross living area(sq.ft.) ' porch) 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" 2 \ The Commonwealth of Massachusetts tiy."""Allk 1, Department of IndustrialAccidetzts 1 Congress Street, Suite 100 ...4 j, Boston, MA 02114-2017\kr www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,D met t'T p i y Ft(I P Pe ./ Address: „Q5 sq.(I] 8F2terca< RD City/State/Zip: S,?P ,1,,,,,D i e f o2b Phone #: 5Qg, • 332 5'6 t Are you an employer?Check the appropriate box: 1. I am a employer with Type of project(required): ❑ employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. ❑ New constdelinrUCtlOn any capacity.[No workers'comp. insurance required.] 8. El Remodeling • 3.g1 am a homeowner doing all work myself [No workers'comp. insurance required.]I. 9. [1] Demolition 4.11 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.� Electrical repairs or additions 5.❑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.: 13•[I]Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per,MIGL c. 14.H Other 152,§I(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: 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 pol cy 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert'y!JAM ze .gins andpenalties o ��d f perjury that the information provided above is true and correct. Sienature: feed'��!v 7/9/. )2___Date: Phone#: c®$ ' 3 32'`t(og ...— 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#: TOWN OF YARMOUTH c,"„ BUILDING DEPARTMENT SC MATTACMECSE. � 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 G HOMEOWNER LICENSE EXEMPTION • PLEASE PRINT: DA l'E: JOB LOCATION: Q3cTII1 13aCeIeSD S. tia,p6mtirtg NAME, .. r STREET ADDRESS SECTION OF TOWN "HOMEOWNER" � rTA[/ rilln,v 5C6' 332 '9' A2 ,TA ` 332°Q682 NAME HOME PHONE PRE NT MAILING ADDRESS 23 S ri 111j Q© er)t IR/ )n WORK PHONE S4 yA Vt, r ot-f rt11 M 02 L.I CITY OR TOWN STA 1'B 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 perfoiuied 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 requirem nd let he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE 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. Yes No If you have checked ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy 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. Check one: Signature of Owner or Owner's Agent Owner 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 422,3 St/7/ I? 1&t'kJ Qi S . a ,n u j 6'�l )� Q`Z 6o6 Work Address �3 Is to be disposed of at the following location: 7( ,4A„ /JJs / 4c_/i/t y Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. r / asy /07 Signa t- of Applicant Date Permit No. ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: 13 3.1 1 g K R,D S' Yaw he /id 61a�/ Scope of Proposed Work: F,I t. 4 0 Papaw PS Deinqpa ux(MO eza =�i�-� _ MreiziaA wQ I(5 to /Q T cd1. c14,31410 . 'ET'120c k` Rs1 -i�7c,n 1 Are• #Dose / p_ki ' FIN/ map eyrepia4 w y/ & C SIel Date: j'$ Pac 1w) 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: tr Health Dept. —508-398-2231 ext. 1241 Conservation —508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 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 yo`.�coo•eration. Recei• ,r'ement: I App .nt's Signature /q/ ©`� Date Rev. March 2022 . ^ Sears, Tim From: Sears, Tim Subject: 'filiPPSOO@gmail.com, 23 Still Brook ve reviewed Your . .---ion . ^."=.=me^vmeuenaneeded ^ ealth Departmentsign off � cx/u/ngmu proposed floor plans with dimensions Please submit these items for review Tirnothy Sears C8O Deputy Building Commissioner 'lovvnofYarmouth 508-398-2231Ext. 1259 1 rtt tk R., TOWN OF YARMOUTH 544,, 4, f° HEALTH DEPARTMENT ,..r PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To he completed by Applicant: BuildingSite Location: L , /a-R, ni-cu..(r; /1-M Me-{, 641/ Proposed Improvement: r, 1 Applicant: DtAA <7 kn‘ V F11 I P PCB v Tel. No.: g? Address: ,f t // ' P- P iti4 C` ( i I_-, fC tt'xc t7l?' Date Filed: 2 *"/fyou would like e-mail notification of sign off please provide e-mail address: Owner Name: pr+ti'f .t l"r 11! PC?V Owner Address:- cl, I\ R) S JO v u 2(rt-k Owner Tel. No.: cf-CX &lb ea 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; planlabeling (2.) Floor ALL rooms within building C© ODI (all existing and proposed) MAY ? 7 2022 Note:Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer HEALTH DEPT. with fee. 2.,\17#1,_ ( '`.---'''' REVIEWED BY: DATE: t//7/-2- 'IL' COMMENTS/CONDITIONS: PLEASE NOTE tfvLce ) Ae ✓h cc. is 3 /-36 „G . r { . ...--.—...... . I ! t. ..._______. . . • . p.t.) .......__... • N i ; . • :Cr) \ 1--I . in :-,--.,... ,'i1; hull' r— .1-..: ('., .). . . !'-•".. : • , I ,,,, hull • ..-,,. . Z. . . • :1 P...) (c:)., , (... ...) . .• , . . . . (...) 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