HomeMy WebLinkAboutImage_001.pdf - BLDX-23-15481 20871ONE & TWO FAMILY ONLY. BUILDING PERMIT
Tolvn of Yarmouth Building Department
I146 Route 28, South Yarmouth, MA 02664-4492
508-398-2231 ext. l26l Fa\ 508-398-0816
Massachusefts State Building Code, 780 CMR
BLtilding Permit Applicqtion To Construct, Repai., Renovate Or Demolish
a One- or Trvo-Fanily Dv,elling
l.l Pro rR Address:
0 )E R!t t \. Yri \ro r t lJ Assessors NIap & Parcelliumbers
l.la [s this all accepted stleet? yes {no Ivlap Number ParcelNumber
I 3 Zonins Informatio(-t{0"n:
ItSrDrNCE LJ Proo!.1 tt,ertl Dimensions:o rl 7119
Zoning Disrict Proposed Use
1.5 Building Setbaclis (ft)
Front Ya.rd
Required Piovid.d
Lot Area (sq ft)
Sr,lc Ya-rds
SICTIOr" 2: PROPERTY OWNERSHIP'
Frontage (ft)
Re3r Yard
1.8 Servage Disposal System:
ivlunicipal 0 On site disposal sysrem
1.6 lvater Supply: (NI
PublicJ Pr:rrt: C
G.L c .l0, $i4)
J
2.1 Ownerr of Record:JvAIE? Al,RA,J \^/tS ?YapF.lrrI AA 026\ l
I nrs sectlon for Othclal Use UDI v
Building Polmit Numb€r:Date Applied:
Building Off;cial (Prior Name)S ignarure I ).,i(
SECTION l: SITE INTORMATION
Requircd ProlideC Requirerl ProvideC
Check if yestr
1.7 Flood Zone l[formation:
Zooe: \ Ourside Flood Zone?
Nane (Print)Cit), Statc, ZIP(o rirFE0.\$N l!E
),io. and Street
Brief Description of Proposed Workz (A(!0 F
Telephone il Address
SECTION 3: DESCRIPTION OF pROpOSED tVORK:(check all that appty), (-/v1-
t t.ltl ,N0 !v lN Do\J \lJ t*lb
Estimated Cosrs
Labor and Materials Official Use Onlv
l. Building Permit Fee: S-- Indicate how fee is detenninedtr StaDdard City/Toun Application Fee
tr Total Project Cost3 (Item 6) x multipLier x2. Other Fees: S
List:
Total A.ll Fees: $
2. Electrical
lb
Check No. _C
tr Paid in FUU
heck Amount: _Cash Amount
E Outstaading Balance Due:
New Consrruction tr I existing euitaingd Ou,ner-Occupii a r/ i nepni.rlt; 3f Alteration(s) tr Addition tr
Demolition D Accessory Blde. tr Number of Units Other tr SpeciS
SECTIOT- l: ESTITVIATDD CONSTRUCTION COSTS
Item
l. Building s ct0,!Lg
S
3. Piumbing s
4. Mechanical (HVAC)s
ressloD5
5. Mechanical (Fire
S
6 Total Project Cost S
htlnil
5.1 ConstructioD Supervisor License (CSL)
NBjlle ofCSL HolJe.
No. and Stre€t
Unrestricted to 35 000 cu ft.
Ciry1Town, State. ZIP
Te ne Email address
5,2 Registered Home Improyement Contractor (HIC)
!flC Compaay Name or HIC Registrart Narne HIC Registration Number Etpiration Date
No. and Street Email address
Ci o!1Tl State, ZIP Tele ne
Workers Compeusation Iusurance affidavit must be comp leted and submifted lvirh rhis application. Failwe to providethis affidavir yill result in tire detrial ofthe Iss ce of the buildiDg pemir
Sigoed Allidavii Anached? Yes No
SECTIO\ 7a: O\1\-LR AUTHORIZATIOS TO BE CO}IPLETED \1}IENo}\\.ER'S AGENT OR CONTR,{CTO R APPLTES FOR BUILDII{G PERIIIT
l, as Owner ofthe subject properry, hereby au-lboiize
to act on my behalf.in all matters relarive to lvork authorized by tbis building permit application
PrL'lt O!v':ler's Name rElccnonic Slenature)Drte
SECTION 7b: Ow\i'ER'OR AUTHORIZED .4.GENT DECL.{R{TIO\
By entering my name belolv, I hereby attest urder the paiDs ard penaltles ofperju) that all ofthe il]formatioo
cotrtained h this applicatioq is true and accurat. to the bes! ofmy knorvledge and understandlng.
.)!Afi.Et A0 RAr t 1t- {f - li
Print Owner's or,{uthorized Agenas Narne (Elcctronic Signature)Dat".
.\OTESI
l . Ar Owaer rvho obrains ajuilding permit to do his,fter o,,t n rvork. or an owner rvbo hires an unregistered cootractor(not resist--red in the Home Improvetr}ellr Conhactor (] C) progan), will lro/ bave access to the arbirationProgram or guaxant_v fund uDder M.C.L c. l4lA. Other important infomation or the HIC Prog.am can be fouud atw w-w.mass. gov/oca Iaformation on the Construction Superuisor License can be found at wr.v rv. mas s . go v/dps2. When substaDtial worl. is planned, provide the information belorvTotal floor area (sq. ft.)(including guage. finished basement/antcs. decks or porch)Gross living area (sq. ft.Habitable room couDtNumber of lueplaces Nur.ber o[ bedroomi -... -.....-.-
-
Number of batbloom
T,?e ofheating syste m
'
---_
Number ofhalitaths
Number ofdecks/ porches
Ooen
SECTION 5: CONSTRUCTION SER!,ICES
Licensc Number
List CSL Tr?e (see bclow)
Expiration Date
Type Description
U
R Rcstrictcd I&2 Famil Dw:l\I 1,'[aso
RC Roofi Coverin
rVS Window and S
SF Solid Fuel Buming Appliances
lnsulation
D Demolition
SECTIoN 6: woRKERs' collpElrsATIoN DtsLIR{f{cE AFFIDA!-IT (NI.c.L. c. rs2. s 25c(o)
roJotalTP Sct Fq Co t'Proj
T)?e ofcooling system Enclosed
ootage" may be substituted for ,,Total
Th e C o mmo n w ea lth of lllass ac h us ett s
D ep artme nt of I ndtctr ial A cc id.e nts
1 Congress Street, Stite 100
Boston, MA 02114-2 017
www.mass.gov/dia
satiorl Insurance Affi davit: Builders/Contractors/Electricians,?lumbers.TO BE FILED WITH THE PERIVIITTING ALITHoRITY.
\\'olkers'Compen
Name (Business/orgrizaiio tndividlal): J! A p tt IrlO
Address 6o :rfFr Iloru Avt
City/State/Zip V t :l yln no,,rr I hA ozrtl
Aft you .n .mploy.r? Ch€ck th. appropri.tc bor
Btion
I an a employer wrih --cmployees (full and/or pa(-rime) *
B \r S
Phone +: 15oY)9(0 - {.r62 }
Type of project (requirecl):
c!nfo
5e t
').
l d
I am a sole proprietor or pannership and havc no arn,rloyees work,nq for mE rnany capzclty lNo workars,comp. tnsr.rrarce relurrcd l
I aft a homcowner doing all work myself [No workers. comp insurance requrred ] r
a D 11. u 13-.."a"r and will be hirint conlractors to conducr all work on my proDcny I wiliensurc that all contractors althcr hava workers, coap"nr"r,on lnrr,rn.a o, .L rft.'proprictors with no amDloyces.
/ . L__l
8
9
New constructioI
Remodeling
Demolition
Building addition
Electrical repairs or additions
Plumbing repairs or additions
Roofrepairs
I.i E other wrNDtv!rDrlu [i
I(l
I am a gencral contracror anC I havc hircd thc sub-con-lractors lisrcd on Lhe anached shccrThese sub-contraclots hav! employels and havc workers, comD. insurance t d
il
12
tl
5
i Homcowrers who submit thrs
We aie a corporaUon anC ,ts officcrs have ererctsed tnetr rrsh! ofexe:nptton .lel5l, Sl{aJ. and we have no.mplovecs iNo workers. compl rnsr*;;; I;;;:;r rvlcl c
,]
,
*Any applicanr thal che.ks boy 9 I mus! also fiil out rh. secton bclow showing rheir worl.crs'affjdavit indrcanng thcy are doaig all work aod then hire oursi
compeasalion policy tnibnnahon
de contractors mus! submit a new atidavr! indicatrb-coniiacrrrs anC stetc \,nerner cr not .hose cnulres
lconr.uctors rl.rut chcck ttris Uor musi attachad an adCittonal sheet showing the narne ofrhe suemployees. If fie sub-contrac:ois have amDloyecs, lhcy mJsr
og such
harepaovrd€ their woakers' ccnp. pohcy number
I am an employer that is providing \)orkers,it{ormdtion,
Insurance Company Name:
c
rj
ontpensatiott insurancefor my employees. Belote is the policy anttjob site
Policy # or Self-ins. Lic. #
Job Site Address;
Attrch a copy of
-
the lvorkers! .o.punrrtion potiiE.i iiln prg. Ghirli
Ciq,/State/Zip
nq the policy number and expirntion d,rte).Farlure to secure coverage as required under Ir4GL c. 152, $25A is a cri:linal violarion punishable by a fine up to $ i,500.00and,/or one-year imprrsonment, as well as civil penalties in the form of a STOp WORK ORDER and a fine of up to $250.00 aciay against the violator. A copy of this statement may be forwarded rc the Office of Investigatio ns ofthe DIA for insurancecoverage verific n
I do hereby ce ttttcler llrc pains and penalties of pe ury th(rt the i lornwtto n provided above is true and cortect.
re
Il
City or Torvn:
Perm it/License #
l. Electrical Inspector 5. plumbing Inspector
Phone #:
OfJicial use ong. Do not Nrite in this area, lo be completed by cit! or tovn ofrtcial.
Depa rrmert 3. City/Town Clerk
Contrct Person:
lssuing.Authority (circle one i:L Board of Health l. Buildine
6. Other