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ONE & TWO FAMILY ONLY- BUILDING PERMIT
1----- v E ® Town of Yarmouth Building Department :-
- — 1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 (4.'4.JU •
6432.. Massachusetts State Building Code, 780 CMR
B rildieg Permit Application To Construct, Repair, Renovate Or Demolish ,,• ,. '
BUILD' C� MENT a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: j3/ b_7i3-Obb 1 g-,5-- I Date Applied:
is>iv\ SQ.Iac5 7,ii JLI\
Building Official(Print Name) Sign re Date
SECTION 1:SITE INFORMATION
1.1 Proper Ad_ci ress: 1.2 Assessors Map&Parcel Numbers
iY Pie ep 5�4,vr coo c'e 6rat. i 44 - '-
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
0,4<aan•
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
C. 3 , `t- t 5 L5 .ee . D -t-
1.6 Waterer Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public>23" Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system Fle
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:/vn- a,,,i a WI t C.P Lc.n A/ 9 A r�0 0,r to p O nT vv�,a 0 Z.4.7.<
N e(Print) City,State,ZIP j
tit Pt4e454 eoie eirz.“_e_ g(GO 836 412ii
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied EK Repairs(s) F2 Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
s7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $ La,pp p — 1. Building Permit Fee:$ ¶ Indicate how fee is determined:
2.Electrical $ 11 Standard City/Town Application Fee
0 Total Project Cost3 tem 6)x multi lier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: NO))/(
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash unt:
6.Total Project Cost: $ 0 Paid in Full ifil Outstanding Balance D e:
a���'
f �a
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) f�l� 7 g
Poo,ALO iJ a-to€tL License Number Expirati Date
Name of CSL Holder
d L$� List CSL Type(see below)
No.and Street Type Description
y o v r« Unrestricted(Buildings up to 35,000 Cu. ft.)
*-7 Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
c-6$-`3(i Z-4itfte/ fb.LIA law MS sr I Insulation
Telephone Email address ( " D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Loo9oq 3fzi
t.D v L-110ezx.2AJs29 o,e2 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
2a 2 �LvP ) 4-4 �itoq L tWn.734/, edf11
No.and Street Email address
ti.vvvl — e Ce 1<-
City/Town, tate,ZIP Telephone t- edhZ i wt c, C&e►�
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 Issuanc .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 yet ,A c 1-1 1►44 t 84L,12,104
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.
.�_ N 4Lo bl ltiL en), i o
Print wner's or Authorized Agent's Name(Electronic Signature) 7! 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.eov/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"
r
The Commonwealth of Massachusetts
lab*. 1. Department of Industrial Accidents
1 Congress Street, Suite 100
��t, Boston, MA 02114-2017
stir—,.,.•›� 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): %®,•, Lo 14 niz.4,, ;, ip ,ft,_
Address: go C.,p R >J
City/State/Zip: lrs r,,,j Phone #: Se g 36Z ---6Q-9
Are you an employer?Check the appropriate box:
Type of project(required):
l.❑lam a employer with employees(full and/or part-time).*
7. ❑New construction
2. 1 am a sole proprietor or partnership and have no employees working for me in
ca aci 8. Remodeling an •
y p ty.[No workers'comp. insurance required.]
3.E I am a homeowner doing all work myself[No workers'comp. insurance required.]t 9. ❑ Demolition
4.E I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 C Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp. insurance.t 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.. 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:
Policy#or Self-ins.Lic.#: Expiration Date: •
Job Site Address: 7
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ude./, ee Date:
Phone#: •Sdcg ,lZ—e.(/.5c<
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#:
i a
;01" YAK � TOWN OF YARMOUTH
of _° BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DA'1'h:
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER"
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATV ZIP CODE
The current exemption for `Homeowner' was extended to include owner/occu ied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who do s not possess a license,provided that such
homeowner shall act as supervisoi\ (State Building Code Section 1 R5.1.3.1)
Definition of Homeowner:
Person(s)who owns a parcel of land on which he/she resides o'intends to reside,on which there is or is intended to
be, a one or two family attached or detached structure assess• to such use and/or farm structures. A person who
constructs more than one home in a two-year period shall n• be considered a homeowner; such"homeowner"shall
submit to the building official, on a foini cceptable to th- suilding official,that he/she shall be responsible for all
such work perfoiwwied under the building p:rmit. (Secti'An 110 R5.1.3.1)
The undersigned `homeowner' assumes res r.nsib' ity for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulation .
The undersigned 'homeowner' certifies that e she understands the Town of Yarmouth Building Department
minimum inspection procedures and req rement and that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE: /
I have a current liability insri'rance policy or its substantial eq 'valent, which meets the requirements of MGL
Ch.142. Yes I\10 ,
If you have checked ves,please indicate the type coverage by check ig 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 y! /2/- Sx24/2 &uve eire-&-e
Work Address
Is to be disposed of at the following location: ,% = /Pac/>'.r 14A/a c
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Applicant Date
Permit No.
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Sherman, Lisa
From: RICHARD GEGENWARTH <r.gegenwarth@comcast net>
Sent: Wednesday,June 8,2022 3:16 PM
To: Sherman, Lisa
Subject: Re:22-EB072 41 Pheasant Cove Circle
Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are
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.
I take it that the new porch would be using stainless steel cables to allow for better visibility. Since it is
not visible from the road or nearby properties I would giv it my blessings. It will have to pass structural
design/strength at the Building Dept.
Richard
On 06/08/2022 1:57 PM Sherman,Lisa<Isherman@yarmouth.ma.us>wrote: •
,4,41111E-
iLM 0 8 262:i
Hi Richard, I YAt
D KING$iliGH*Ay
Resident would like to rebuild a Juliet porch that was taken out by a tree at 41
Pheasant Cove Circle. The first picture shows the original porch, the second the
house with the porch remains removed, and the third the porch style the resident
would like. The porch can't be seen from the street.
Please let me know if you need any additional information.
Thanks Richard,
Lisa
Lisa Sherman
Office Administrator
Old Kings Highway Committee/Yarmouth Historical Commission
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