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HomeMy WebLinkAboutBLDR-23-11035 a ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department l'il 1 146 Route 28, South Yarmouth,MA 02664-4492 / 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code, 780 CMR _ Building Permit Application To Construct, Repair, Renovate Or Demolish • ' ' a One-or Two-Family Dwelling I This Section For Official Use Onl Building Permit Number: L /. Z3 '//d1 Date Applied- _____ 1,-, 491\;5 (/43 RECEIVED Building Official(Print Name) ature SECTION 1:SITE INFORMATION MAY 2 3 2023 • 1.1 Properly Address:p,�/�' , f�� � � ' 1.2 Assessors Map&Parcel Numb rs Z j�j/rl ----- BUILDING DEPARTMENT 1.1a Is this an accepted street?yes �' no Map Number Parcel 11Th -r -- 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 Private El Zone: _ Outside Flood Zonz? / ` Check if yes': i . `n SECTION 2: PROPERTY OWNERS I E C :: E V 71 D _ 2.1 Owner'of Record: p,� r75. / `� V 5.) Name) s,t uU dear _ nc y`'�City, State,ZIP AUG l i 2023 9 ' Dacts BUILDINr nFPARTrdENT No. and Street Telephone By: Email Address_, .- SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) X Alteration(s)J( Addition k Demolition Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'`: gq,lbccaze icatieh / /bD iirdiry Aaakt g'c froNir Okter text it k i rJI'r c Tel !J Iti,daU► s t frJ 56 c ' Y/Ikc&� -pewi 0,90. tip / Of rft , SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official se Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ �3 Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 106,0 ( j L/L fl 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash :.... . . 6.Total Project Cost: $ 1(}4 DOD 0 Paid in Full 0 Outstanding Balanc,Due:4)31 vW s'r �/ i5I'; • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Su ervisor License(CSL) Cs' / _do( (go C tyfz,y License Number Expiration Date Name of CSL Holder 01\6(y S, S� Ave, List CSL Type(see below) S J No.and Street" YC/ Type Description i Unrestricted(Buildings u to 35,000 cu.ft.) " 3 � I Restricted 1&2 Family Dwelling City/To/ftq, i, tate ZIP �� M I Masonry RC Roofing Covering WS Window and Siding I SF Solid Fuel Burning Appliances Telephone /Qt,5 ,tybo+ J� d VS �ft:44,(ail I Insulation P mail address D Demolition 5.22 Registereded Home Improvement Contractor(HIC) J.75I28 Z`/ H1 C/ eci J •.B r FCC )c.qe el / ( !' HIC Registration Number Expiration Date o. d Str et �� J2" Ati Lek0‘�ii4/hd61�er etiaGm� � ,{� I li I Vt ,/,Q 6 Z 73 Email addre Ciitty/'I , State,ZIP Y `I16 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 ❑ 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. e_ Print Owner's or Auth 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.) (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" 1` SECTION 5: CONSTRUCTION SERVICES S.1 Construction Supervisor License(CSL) C� O - ' l,4L(_ZLf 11 k License Number Expiration Date i Name of CSL Holder U List CSL Type(see below) i Na' eel _ Type Description I and � Unrestricted(Buildings up to 35,000 cu. ft.) __ ,N.. . ... .._, R Restricted lSc2 Family Dwelling City/Town,State,ZIP1_ Ni_ Mas©nr RC Roofing Covering ._ _ . WS Window and Siding SF Solid Fuel Burning Appliances i I Insulation Telephone __�__. — Email address D Demolition 4 S.2 Registered Home Improvement Contractor(HIC) /7 . 1 t tY 1*- HIC Registration Number Expiration Date HIC'Company Name or HIC Registrant Name i I No and Street Email address `i`v Towri.State,ZIP � Telephone SECTION 6:WORKERS'COMPENSATION I'i4ISURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) '4orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide : is affidavit will result in the denial of the Issuance of the building permit. Sinned Affidavit Attached? Yes 0 No .......O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN a OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i as Owner of the subject property,hereby authorize t ty i� L,GL_ i permit s5?r9 4A :��act on my behalf. in all matters relative to work authorize by this buiidin�permit application. S/(1� �ZA/fCy419 fi /.c s..'�4 N3 of D ,t.l„ .6-7 — # Przt,J / 'onicSi. :tire) Dat i/• (ECTION 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 --(itha:th_.a this application is true and accurate to the best of my knowledge and understanding, . , .e `'r Air'orized Ag ;i'3 j\ame(Electronic Signature) Date NOTES: x A"01%-ner lx1-10 obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the I4rime`Improvement Coltaaetor(HIC)Program),will foot have access to the arbitration . : ; program or guaranty fund under;MI.G.L.c,;142A,Other important information on the H.IC Program can be foul d,at -.,, nos ._ ,1La at-urination d:a e€Construction Supervisor iv cuac ttllu+ . U uu .Fi'Fr W.iiaSS.aovldgs.i woen$441413.tat.work is nlannera -, ,. _, ,' .`:::nation below: •9e,finished basement'�'ttics,decks or porch) - ,1}l room Intuit •er of bedrooms .;,egg Open __ ,.__ _.. s C. ' rfr ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: /q 034/ / ' W./Olt/darn'? Scope of Proposed Work: /' �� � 4-0ID U7-'/, ty 661141 , L e /(l e,141 A/et J e 3 ( Op 1 s1- p1 peer 4 Date: 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 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/Jason Moriarty, 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: Applicant's Signature Date Rev. July 2021 F � � The Commonwealth of Massachusetts i qj�l Department of Industrial Accidents _*�-..�.(� 1 Congress Street, Suite 100 ""-''ram Lt Boston, MA 02114-2017 tog " �� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERtVIITTING AU:: : . A licant Information Name (Business/Organization/Individual): / Please Print LeQibl t w(n Address: City/State/Zip: ; .„ 1 1 Z 6 Phone #: D g c ZZ( ,6 I Z Are you an employer?Check t a appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 2.❑I am a sole proprietor or partnership and have no employees working for me in �' Er NewC e1in g construction any capacity.[No workers'comp. insurance required.] 8. emodli { 3.❑I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9 Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building ensure that all contractors either have workers'compensation insurance or are sole addition proprietors with no employees. 1 1. Electrical repairsion or additions 5.C I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 13.n Plumbing repairs or additions j These sub-contractors have employees and have workers'comp, insurance.t 0 Roof repairs 1 We are a corporation and its officers have exercised their right of exemption per MGL c. ,/ 152,§1(4),and we have no employees. [No workers'comp. insurance required.] 14.❑Other *Any applicant that checks box All 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 ins urance suranc in e or m employees.formation. f y Below is the policy and job site Insurance Company Name: Policy A or Self-ins.Lic.iA: Expiration Date: Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing thetpolicy 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 coverag.e verification. 1 do hereby certify under the p ' s and penaltie f perjuty that the information provided above is true and correc t Signature: Date: Phone#: L L Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License r 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#: Clarke, Kristin From: Ed Stafford <lewisbaybuilders@gmail.corn> Sent: Friday, March 17, 2023 1:07 PM To: Clarke, Kristin Subject: Updated CSL Pi r Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are v 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. 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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 ! V td;h1- A'1.1 , Work Address Is to be disposed of at the following location: 744;4 a T ,fib Z Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Application Date Permit No. °F• � TOWN OF YARMOUTH 0 BUILDING DEPARTMENT a NATTAGnECSE�9 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 PLEASE PRINT: HOMEOWNER LICENSE EXEMPTION DATE: JOB LOCATION: "HOMEOWNER" NAME STREET ADDRESS SECTION OF TOWN NAME HOME PHONE WORK PHO►' PRESENT MAILTh G ADDRESS CITY OR TOWN STA i'h The current exemption for 'Homeowner' was extended to include owner— . cu.ied�elODElines of one or two units and to allow such homeowners to engage an individual for hire who doe of possess a license, rovided that su homeowner shall act .s su.ervisor. (State Building Code Section 11 t •5.1.3.1) p ch Definition of Homeowne . Person(s)who owns a parce of land on which he/she reside sr intends to reside,on which there is or is intended to be, a one or two family attach:d or detached structure ass-.sory to such use and/or farm structures. A person who constructs more than one home 'n a two-year period sh. not be considered a homeowner;such"homeowner"shall submit to the building official, o a form acceptable • the building official,that he/she shall be responsible for all such work .erfo1rned under the b dine .ein t. section 110 R5.1.3.1) The undersigned `homeowner' assum: re. .onsibility for compliance with the State Building applicable codes, by-laws, rules and regu :tions. Code and other The undersigned 'homeowner' certi 'es that / she understands the Town of Yarmouth Building minimum inspection procedures . d requirem- is and that he / she will comply with said ro Department procedures dures and HOMEOWNER"S SIGNA ' APPROVAL OF BUILD 1+ G OFFICIAL INSURANCE COVE• • GE: I have a current liab; ity insurance policy or its substantial equivalent, uch 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 re 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