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Home My WebLink AboutBLD-22-007318 . PO (/zzii& ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 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 — .�� ' D a One-or Two-Fimiily Dwelling This Section For Official Use Only J U N 211 2022 Building Permit Number: ;th' Z 31 , Date Appli - 1)m �� 7 Gr:�4- BUILDING DEPARTMENT Building Official(Print Name) ignature Date 3 S.60 SECTION 1:SITE INFORMATION "' rig C-r y 1.1 Property Address:,, 1.2 Assessors Map&Parcel Number 3 .-'C" ape-O-�h t) 1.� 4 7 /7 'I- lia Is this an accepted street?yes / no Map Number Parcel Number 1.3 Zoni j 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 30 1.6 Water Supply: (tvi.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public d Private 0 Zone: _ Outside Flood lone? Municipal❑ On site disposal system a Check if yesIg SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: o / i (Og>< r/Vil ti PiAVOJE.}1 YAP 14a� W/044, ZC3 l • Name(Print) City,State,ZIP 4r.4 600-0-- .f'Q 4 Oi? 36(/ k7 sR ,.1 1O 9► i4.uQ(ofr No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 I Existing Building❑ I Owner-Occupied ❑ I Repairs(s) Cl Alteration(s) iil , Addition ❑ Demolition ❑ I Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Wor : it'f - S'ter 66D 1O&/ f-ki C C k 01'1', i, q T-i- SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ ` " CO 7 1. Building Permit Fee:S .ice) Indicate how fee is determined: 2.Electrical $ 3 (200 ElStandard City/Town Application Fee Cl Total Project Cost3 tem 6)x multiplier x / 3.Plumbing $ ` 00 2. Other Fees: $ -�; 51y It�r 4_Mechanical (HVAC) $ List e ,l� 5.Mechanical (Fire - — ` , Suppression) $ Total All Fees:$ q Check No. Check Amount Cash oSuny n A\Pill 6.Total Project Cost $ l/ ❑Paid in Full 0 Outstanding Balance e: Ii _n SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C _/ 9 0 ; / License Number Exfoiration Date Name of CSL Holder n List CSL Type(see below) 1.4,4f,31 P1<'7' a No.and Street Type Description / U Unrestricted(Buildings up to 35,000 Cu.ft.)_ ��"1' `�* � ��`�� ®" R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry RC I Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances iOr 2i7 NksUdase.m Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /97 1:144/i.6 tit I('"c" HIC Registration Number Expiration Date tug Company Name or HIC Registrant Name 6' / 7 .ate' r /� E 777 M �Rc N .and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT IDAVIT(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 Ll SEC 1'1ON 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 /2,C N40 /C�/et it e k to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signatur ) 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. 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.sov/oca Information on the Construction Supervisor License can be found at www.mass.nov/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" §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 `'( eayq-61, L Work Address Is to be disposed of oat the following location: /0 L Af ice` / ,gRGJ t UI D?SPO5TX- OR P/k/ft s14N,714,'1tO,Q aR 1313611i DYs'ID05,4L. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. J`"I Signature of Application Date Permit No. The Commonwealth of Massachusetts a=41t= Department oflndustrialAccidents 1 Congress Street, Suite 100 • ,. Boston,MA 02114-2017 i. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMiITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): � /�i •. ix Address: ". $7 City/State/Zip: 8.+ t i''A, A14 C. A--f Phone#: ( ' Are you an employer?Check the appropriate box: Type of project(required): l.Q I am a employer with employees(full and/or part-time).' 2.a I am a sole proprietor or partnership and have no employees working for me in 7. Q New construction any capacity.[No workers'comp.insurance required.] 8. El� Remodeling 3.❑I am a homeowner doing all work myself(No workers'comp.insurance required.]t 9. Q Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will I4 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 1•❑Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other I52,§I(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: Attach a copyCity/State/Zip: 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$I,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 roz the s ird a of peijitty that the information provided above is t ue and correct. Signature: Date: -(-;%/ Phone T: 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): I.Board of Health 2.Building Department 3.City/Town CIerk 4. ElectricaI Inspector 5. PIumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of BuildingR ulatikns and Standards Const ' isor A CS-106980t ` "Tres:07/12/2022 RCHARD 206 STATE ~1• y 4 O BI EWSTER ;r, "; ., 1 Commissioner cYaee /. `t Errnck , '•THE COMMONWEALTH OF MASSACHUSETTS • :Office of Consumer Affairs&Business Regulation i $ . HOME IMPROV�Nf CONTRACTOR TYP . tfali dual. tton 'C� 70`x . .11/2612024 RICHARD•KIRCHNER. , `a 14 'D/B/A RHIE BUILDERS, ` a ''""it a §. RICHARD KIRCHNER 206 STATE ST BREWSTER,MA 02631 'K� Undersecretary' • t Y�.k M TOWN OF YAROUTH 5 ' ti:r-.) c.,... zifr,_" HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: W ,/ ^ _. -. , f. Proposed Improvement: f 1 pi- Applicant: /4 Tel. No.: Address: Date Filed: **If you would like e-mail notification of sign off,please provide e-mail address: Owner Name: Owner Address: Owner Tel. No.: RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, Gli 1-11 :1EIT and septic system location; (2.) Floor plan labeling ALL rooms within building JUN ' 2022 (all existing and proposed) — HEALTH D E PT Note:Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: ` � DATE: C 7e, COMMENTS/CO ITIONS: PLEASE NOTE ul l rz 5(''(- F Vc -T i2 (m ed v6 owt_r