HomeMy WebLinkAboutBLDR-23-12883 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department y -
1146 Route 28,South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 �' �'�
Massachusetts State Building Code,780 MLR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
jt/ This Section For Official Use Only? RECEIVED
u
Building Permit Number: L/.) -Z3- %Z 4 3 Date Applied:
i;ti, . �' 9— ')- 3 AUG 2 2 2023
�
Building Official(Print Name) ignature Date
SECTION 1:SITE INFORMATION BUILDING U E PA f T M E N T
ay __ — .
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
J0(, t‘,/. 1.\Pc.)a cN(-Al)e- 2 A GS' k 46
1.1 a Is this an accepted street?yes f no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
2 3 C. '2, Q
Zoning District Proposed Use Lot Area(sfq 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,i 54) L7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: _ Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner'of Record:
\<<i y ,o ..,01 .,. ?c:, r ce_
��\ , va r- inn u � a-V } 2 Z. -T 3
Name(Flint)) Ci St
j0 Ce 1104..1 1,\(.41 n ors r,�!- ✓e_ �sib-7 7.�-20 f¢ Il', Fa rc e, e c owt c it,3t•it
o.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction 0 I Existing Building❑ I Owner-Occupied 0 I Repairs(s) 0 Alteration(s) ❑ I Addition 0
Demolition ❑ I Accessory Bldg. 0 Number of Units Other Specify: S
Brief Description of Proposed Work2:
W.: Y\\6
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
•
Item Estimated Costs:
(Labor and Materials) Official Use Only
r.
I.Building $ 0 _ I. Building Permit Fee:$I G _Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town.Application Fee
❑Total Project Costa(Item 6 x multiplier x
3.Plumbing $ 2. Other Fees: $ 35- 0(
4_Mechanical (HVAC) $ List: el /Cy 1/LI
5.Mechanical (Fire .
Suppression) $ Total All Fees:$ ' - -
6.Total Project Cost: $ Check No. Check Amount: Cash Atno t:
�-� 0 0 Q' '`❑Paid in Full 0 Outstanding Balance Due: 133
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,own,State,ZIP R Restricted l&2 Family Dwelling
lkl 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 ❑ No .❑
SEC:LION 7a: OWNER AUTHORIZATION TO BE COMPLETED WREN
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
coElt fined in this appli adonis true accurate to the best of my knowledge and understanding.
F
Print Own is or Authorized Agent'sNatne(Electronic Signature) ate
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.aov/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"
o.f. ���E R TOWN OF ARMOU i H
AA
-1' BUILDING DEPARTMENT
4 ^yt; 4°v 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: 2 ? o z
JOB LOCATION: 7 O C. t \- \ J r •r vs-t G T k
NAME STREET ADDRESS 'SECTION OF TOWN
"HOMEOWNER" '� c A \ ,r L .1f 0 R — 7 7-S-- Z c> 1 4—
NAIvTR HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS _t O (,. h A(,4
o 673
CITY OR TOWN STATE 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 buildins 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 t he/ she understands the Town of Yarmouth Building Department
minimum inspection procedures and uirements a d that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNA
APPROVAL OF BUILDING 0
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
Cha ter 142 of the Mass. eneral Laws and that my signature on this permit application waives this requirement.
v^^ Check e:
5i mat re of Owner or Owner's Agent Ow r Agent
litho wnriicexeanp
r
§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 _jr". r- o
Work Address
Is to be disposed of oat the following location: id.,r ,,,` u t-h L,
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
Sign tore o pplication 7 Date
Permit No.
The Commonwealth of Massachusetts
I 9i�1► Department of Industrial Accidents
lifilli
...1.41,„
1 Congress Street, Suite 100
Boston, MA 02114-2017
Www.mass.gov/dia
Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY,
Applicant Information
Please Print Leoibl
Name (Business/Organization/Individual):
Address:
City/State/Zip: I/.
i_ r ? Phone #: ak'- - 7 0 14--
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_ I am a sole proprietor or partnership and have no employees working for me in 7. ❑New construction
any capacity.[No workers'comp. insurance required.] 8• n Remodeling
3.jv:a I am a homeowner doing all work myself. [No workers'comp. insurance required.)t 9 U Demolition
44..]��I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [1] Building addition
ensure that all contractors either have workers'compensation insurance or are sole
11.Li Electrical repairs or additions
proprietors with no employees.
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance./ 13.❑Roof repairs
6❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]Other
152,§1(4),and we have no employees. [No workers'comp. insurance required.]
*Any applicant that checks box tit 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 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 im. isonment, 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 v' 1. or. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage veri ati, .
AIM
I do hereb erti r under the p.ins 3 zd e
P ,s of perjury that the information provided above is true and correct.
1 Signat a ,_..... _.,___-
,��
Phone T:
Date:
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#:
ONE or TWO FAMILY— BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: 'p(„ kt/ t e e-S\G N r. v G ram\
Scope of Proposed Work:
Date: . Z ), Z' 7 3
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/Scott Smith, 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 cooperatio
Receipt Acknowledgeme I
•
Applicant's Signature I
Rev.Jan. 2019
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Consulting Structural Engineer
Centerville, MAssachusetts 02632-1979 mcudiloOcomcast.net
BARCE SUNROOM Drawn By: MC Date: 7 /17/2020
106 WIMBLEDON DR. Scale: AS NOTED Rev.
Drawing
WEST YARMOUTH, MA 02673 Rev SK-2
File Name: BARCE Pro'ect No.:2020-176
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