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HomeMy WebLinkAboutBLD-23-000500 R E C E 4 EE&ft dVO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department "oF v .._ JUL 2 6 2022 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 i� Massachusetts State Building Code, 780 CMR ...1,7i; 8uII_DING DF�A6TMF:NT By'. ur mg ern.it Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling - This Section For Official Use Only Building Permit Number: 13J'-a3-t)b SOD Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pro e/rr Address I / 1.2 Assessor_s Map&Parcel Numbers as 1.1 a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: � 1.4 Property Dimensions: >rOL )/r9IL. (C.- I( ZLIiCl ..c Pl/8ta 1Z6.11 / Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) .3f1 wart.; 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? Public II Private 0 Check if yes❑ Municipal 0 On site disposal system & SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow er'of Recof 1 1 �/ e, d / ICc1 .1 7 a r.�..a...�L 1Ao.r"- /( o L E, Z 5-- Name(Print)O Ca/� City,State,ZIP 'A tilLr 4.,,,, i4 S©S 3Z65305 brocle. et.s5 oar edc.cit,ft.Ast, ,rf eCaA No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied b I Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:� C Brief Description of Proposed Work2: 1.tss nv-skin_ 1 1.4_/i ev^ei o dam+?e- - .Id_a_tn. 1 AM o✓c- Z. ,to 1+Po. +. .►.ra .uj 5,.mod in 3 or 11 f n C*.J of k' in ( am .- i^iitCoe, ) SECTION 4: ESTIMATED CONSTRUCTION COSTS Item I Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $\c() _Indicate how fee is determined: N.,Standard City/Town Application Fee 2.Electrical $ Z1 co 00 Total Project Costa(Item 6)x multi ' r x 3.Plumbing $ -3,Q 0 a 2. Other Feet:6____ __ Lt D cos 4.Mechanical (HVAC) $ 12c d p c5 List: "1 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount 6.Total Project Cost: $ Z' ; 'S 0-0 0 Paid in Full ilkOutstanding Balance Due _ AID / . SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) OC, 46 3 c( ?lL r I‹ ;.k\-ek ,r License Number • Expiration Date Name of CSL polder f p 10 J 1� S J4, L 1 I List CSL Type(see below) C� No.and Street Type Description v � �" / U Unrestricted(Buildings up to 35,000 Cu.ft.) W' �ti V M 7 / " Ail.fA SS � R Restricted 1&2 Family Dwelling Ci /Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1903 75-cl 87 i.t lrra;✓,®[,eAc:eS , nCd I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ,S�I�(� itloSwrt, I�N.f.'th fir HIC Registration Number Expiration Date EEC Company Name or HIC Registrant Name No.and Street p mail address 1.1 A 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 7 No ❑ SECTION 7a:OWNER AUTHORIZATION TO B COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR' BUILDING PERMIT w ( I,as Owner of the subject property,hereby authorize h 'n / .I r to act on my behalf, in all matters relative to work author' d by this building permit application. i ACI'vv% c 4 o A, 7 'Z.S 1 W Print Owner's Name(Electronic 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 • V._ t,A 41t✓ `7 21. 7.-e Z.Z 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.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.) G.c,s (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Ci gR Habitable room count Number of fireplaces 1 Number of bedrooms 2.- Number of bathrooms t Number of half/baths Type of heating system 6c,5 Number of decks/porches Z Type of cooling system 6ck.') Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 7'he Commonwealth of Massachusetts �= _ /, Department oflndustrialAccidents w 1 Congress Street, Suite 100 i, = lj_ Boston, MA 02114-2017 ~� www.mass.gov/dia No Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): S`eAl,*1 \"(,t,i✓ C „A5 (,/'LA, c- Lit , Address: !(.9& I-1'a uy3 lJ ec,/L )cC.A Evan,c...i`ice 0 vv'd . City/State/Zip: Nick, 61.E 1 t Phone #: & O ?51 CY7 ZO Are you an employer?Check the appropriate box: Type of project(required): I.0 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 $• Remodeling any capacity.[No workers'comp. insurance required.] 9..5111 Demolition 3.0 I am a homeowner doing all work myself'. [No workers'comp. insurance required.]t 10 Ei Building addition 4.❑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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 1 ❑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: 13(OW/1 '{ I3f0 0 — Policy#or Self-ins.Lic.#: Expiration Date: di Ol • Job Site Address: gq at /4'b +a-1 ,'t / City/State/Zip: Attach a copy of the workers' compensation p licy 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 zit der tip sins and penalties of perjury that the information provide ab a is true and correct. Signature: �,. - Date: ? a 2dL2 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#: . ol YARN TOWN OFYARMOUTH u BUILDING DEPARTMENT �` ATTACME[sE. 0� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DALE: eckAlt_/JOB LOCATION: kici 1 , � /a f-.4,0 4 ir,/a®l`I pp N h //Ir/, STREET ADDRESS SECTION OF TOWN "HOMEOWNER" btaCi f"LC..Imi 505' 3 Z6 5.30 5 619 c ZS NAME HOME PHONE WORK PHONE PRESENT MAIL[NG ADDRESS S.q� G CITY OR TOWN STA i'h, 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 peiiuit. (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 un erstands the Town of Yarmouth Building Department minimum inspection procedures and re uireme is that 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 OWNE 'S INSU WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapte 42 of e s General Laws and that my signature on this permit application waives this requirement. Check one: Signa re of Owner or ner' Agent Owner V 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 H 9 Ccd,r LP/ (d/ /cc r.tiw.>'at i0or 1 Work Address ✓ Is to be disposed of at the following location: LOS 1'v.ra-s/ !0, 'V`/ct f"1_0.11't. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. z 2r,zozz Signature of Applicant Date Permit No. • • Office of Consumer Affairs s Business Regulation HOME IMPROVEMENT CONTRACTOR Individual • tu., EYoiration 11/05/2022 KEVIN FAIR F KEVIN J.FAIR 100 HOMERSDOCKV ,stv YARMOUTHPORT,MA-02675 Undersecretary Commonwealth of Massachusetts Division of Occupational Lictnsure Board of Building R ulations and Standards Cons ielibigv. isor CS-094639 gpires:07/01/2024 KEVIN J FAI; 100 HOMER i• ` °; YARMOUTH R • • Commissioner da yq a(....61/4.A.1.,...‘3„, ,_ ed y ,....... ._..:it N�:�r �rTc tie Ai r pi.Ar4 N.40 - 1 z /M r a.. t L 5 - /1c,c4.4-f ,ef„„,, ,..� 6.2I z — M li t. - e ... - , ---tor ' xmom, EIMRWIlmiMr- '?R i E = , , ✓ - INS te, ,: fi1,gN+E 1 Ih 1 L L wl,C C L k,r rc.d&+vs'