BLD-23-000615 Y
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ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department 04Y
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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
a One-or Two-Family Dwelling E E
This Section For Official Use Only 22
Building Permit Number: 8L1 -23-011)(6(S Date Applied:
r S —,r-� ' ,S` 1 l BUILDING DEPARTMENT
Order h+: _
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
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 0 Zone: Outside Flood Zone?
Check if yese Municipal 0 On site disposal system PEr
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
J.444f,It% uCCOi.o 5rdutcilfmu M 0)fl
Name(Print) City,State,ZIP
ao yuRtP cut ?&r- rt-lc&? Gicc lo!& a ccolut9-,ne,/
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. 0 Number of Units Other Cl Specify:
Brief Description of Proposed Work' kE.*lam L /V1if-5tj, S1kI
Tr
cEici iU z0o rS spM,I wfu_ -t,vivu.. km hat pm,- Pooh 2A-=rzzI.S NU 5P-11411-tud' L
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 711/dd® 1. Building Permit Fee:$ l Indicate how fee is determined:
2.Electrical $ jOop 5Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $7,ad O 2. Other Fees: $ e
4.Mechanical (HVAC) $ List: 3 5.[0 ) -3c- t ��5.Mechanical (Fire
Suppression) $ Total All Fees:$
6.Total Project Cost: $ ri"CJ Check No. Check Amount: Cash • iio�t r �--
(�' 0 Paid in Full ® Outstanding Balance D e: 11 `3 �\' d
D
C/�,
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
ksi En-ILL le)
Name of CSL Holder License Number Expiration Date
�� �L��fJ s List CSL Type(see below)
No and Street ,hype
(� Description
✓ Q ) Iwo Unrestricted(Buildin•s up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted I&2 Family Dwelling
NI Masonry
RC Roofing Coverin•
WS Window and Sidin•
"�� ,3 (���� c G` ��� I SF Solid Fuel Burning Appliances
Telephone �^ I Insulation
Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
titL Company Name or HIC Registrant ame HIC Registration Number Expiration Date
•
No.and Street
/f-/ �- d 76 Email address
City/To , 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 pe
rmit.
building P
Signed Affidavit Attached? Yes 0
No 0
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 S
to act on my behalf, in all matters relative to work authorized this ding e p rmit 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 applic on is true and accurate to the best of my knowledge and understanding.
Print 0 er s or i ize Agent's Name(Electronic Signature) -
Date
1 NOTES:
ner 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.siov/d s
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.)
Gross IivinQ (including garage, finished basement/attics,decks or porch)
b area(sq.ft.) Habitable room count
Number of fireplaces
Number of bathrooms Number of bedrooms
Type of heating system Number of half/baths
Type of cooling system Number of decks/porches
Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
IN rThe Commonwealth ofMassachusetts
�' Department of Industrial A cc/dents
MIMI
1 Con press Street, Suite 100
L . Boston, MA 02114-2017
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,� www.ma Q
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information
Name (Business/Organization/Individual): / Please Print LeQibl
y I-
Address: — S
City/State/Zip: - 7�-
Phone #:_ '=3 S3 �aL
Are you an employer?Check the appropriate box:
I.❑I am a employer with employees(full and/or part-time).* Type of project(required):
7. El NeNew2.�I am a sole proprietor or partnership and have no employees working for me in construction
8. [] Remodelin elfing
any capacity.[No workers'comp. insurance required.]
9. C Demolition
3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 10 — Building addition
proprietors with no employees. 11. Electrical repairs or additions
5.0I 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.t 13. Roof repairs
6.❑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.] 1 4' Other
*Any applicant that checks box ill 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
$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'com such.
p.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 CA-A
Address:�j l "LD
Attach a copy of the workers' compensation policy declaration page(showing thetate/Zip:po policy number anFailure to secure coverage as required under MGL c. 152cr d expiration date).
and/or one-year imprisonment, as well as civil penalties in the form of STOP WOnal violat1RK on ORDER and a fine of uppunishable by a fine o o 0.00
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for
coverage verification. up to$250.00 a
insurance
I do hereby cer' tip', u id- he pains and penalties of perjury that the information provided above is true an Signature: ,lifi A d correct.
Ph ./ Date: --ec.
Off zal use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authori Permit/License# •
ty(circle one):
oar
1. Board of Health 2. Building. oarr Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person:
Phone#:
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 7f 01-
Work Address
Is to be disposed of at the following location: ff.!I l�"�(�Ti� d�!�i0
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Sign ure f Applicant
Date
Permit No.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02 1 1 4-20 1 7
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Revised 02-23-I5 •
Fax # 617-727-7749
www.mass.gov/dig
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SECTION S: 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,Q00 cu.,ft.)
R Restricts i&2 Farnilyy Dwelling
City/Town,State,ZIP M 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(SIC)
HIC Company Name or MC Registrant Name HIC Registration Number Expiration Date
No.and Street
Email address
City/Town,State,ZIP Telephone
SEtu 1'1ON 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M,G.L.e.152.§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit wi`ll result in the denial of the Issuance of the building permit
Signed Affidavt Attached? Yes 0 No ......,...Cl
SECTLQN 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMI'I ..
I,as Owner of the subject property,hereby authorize 3 e4* 5at.L.T L{
to act on my behalf,in all matters relative to work authorized by this building permit application.
2
LS.A.La— et—ttere0 - -
flat ame(Electronic Signature)
Date
SECTION 7b:OWNER':ORAU'THORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penaltes of perjury that all of the informaticn
contained in this application is true and accurate to the best of my l nowIedge and understandin .
( Print Owner s or Authorized Agent's Name(Electronic Signature) Date
NOTES:-
I. An.Owner who obtains a building permit to do hirer own work,or an owner who hires an unregistered contractor
(not re 'glistered in the Home (HI )Program),plater Improvement Contractor C will root have arcrsc to the arbiva:tion
program or guaranty fund under M.G.I..c.142A.Other important information on the HIC Program can be found at
wYww.mass.govioca Information on the Construction Supervisor License can be found atwww.inass.aov/dps
2. When substantial work is planned,provide the it ormation below
Total floor area.(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable mom count 1
Number o`er eplaces Number of bedrooms
Number of bathrooms Number ofhaiflbaths
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"
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TOWN 10F YARMOUT .
4441 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
_R
Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 ECEIVED
;IV; 0 4 ./(ci, OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITT
hlvAPPLICATION FOR AUG 0 4 2022
CERTIFICATE OF EXEMPTION
BUILDING—D-63-Al2-TM.ENT
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 cf
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly:
Address of proposed work: 7i cii-triv..crirth Map/Lot ft
Owner(s) ht& ICsit-taL-0 Phone#. ?FP
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address' (C) 14216 STObitION M 0487> Year built /9i2g"
Email: C./GC 304 6 Comcmrt tut Preferred notification method Phone ‘-'" Email
Agent/Contractor Li)rcjj Phone# "i7‘f— 3 —6(121_
Mailing Address- SI cr '-Pr AAA
Email 64:49e ho ine...refradAl (ia kv\ Preferred notification method Phone tr- Email
Description of Proposed Work(Additional papas may be attached if necessary):
geinde Mth-S I" re---)(Ant. Pui neiciArj — foam (m. back (.4 1)ou3e_
,4(Idersan leo 6A-toS rv3/4-1-0.,n Kst
Date.
Signed(Owner or agent • , 8--3
> e that a permit may be required from the Building
Owner/con actoria nti Department,(Check other departments,also.)
) This certific te is ood for one year from approval date or upon dale of expiration of Building Permit whichever date shall be later.
For Committee use only:
n ,
Date._..8142•2 /Approved Approved withl nied
Amount
Reason for denial, AUG 4 2022
A06(1)
I '
CashICK#: t2 YARM
gLo KINGS HIGHWAY
Rcvd by: /-.5.
Date Signed 111.4 12? Signed, 50 afhekici e4,02. t
APPLICATION#:
vs 201
Sherman, Lisa
From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net>
Sent: Thursday,August 4, 2022 2:42 PM
To: Sherman, Lisa
Subject: Re: 22-E1OS 71 Camelot Road
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.
Looks doable and will allow a queen-sized bed.
I approve.
Richard
On 08/04/2022 1:47 PM Sherman,Lisa <Isherman@yarmouth.ma.us>wrote:
Hi Richard,
Resident is remodeling the main bedroom and wants to relocate the windows to
fit the new configuration. The room is on the back of 71 Camelot Road.
Please let me know if you need any additional information.
Thanks Richard,
Lisa UG 0 4 201,1
yARmoum
D g3 HIGHWAY j
Lisa Sherman
Office Administrator
Old Kings Highway Committee/Yarmouth Historical Commission
TOWN OF YARMOUTH
1146 ROUTE 28,SOUTH YARMOUTH,MASSACHUSE I I S 02664-4451
, Telephone(508)398-2231 Ext.1292 Fax(508)398-0836
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
WAIVER OF 45-DAY DETERMINATION
The applicant/applicant's agent understands and agrees that due to the current declared.National
and State public health emergencies the determination of our Application for a Certificate of
Appropriateness/Demolition/Exemption may not be made within 45 days of the filing of such
application.
The applicant agrees to extend the time frame within which a determination is to be made as
required by the Old King's Highway Regional Historic District Act.
SECTION 9-Meeting`, Hearings, Time for Making Determinations
"As soon as convenient after such public hearing; hut in any event within forty-five (45) days
after the filing of application, or within such further time as the applicant shall allow in writing,
the Committee shall make a determination on the application."
Applicant understands that the review of this application will be scheduled as soon as the
situation allows.
Applicant/Agent Name (please print): �l)l... __.
Applicant/Agent signature: .____ Date: $
\ —
_ ,AilkIOu I Asir a 2022
i OW KING SS HIGHWAY
YAAMOu E to 3
OL1'KING'S HIGH vv 'Li
Application• #:
3/2020
Firefox aboutbiank
,--------
ECEIVEN XI ANDERSEN'
WINDOWS & DOORS
AUG 0 4 20 , CREATED DATE I”,i
im-oviouii, SOLD BY: SOLD TO: 41210822
.arising Building Praducts•Hyannis
1400 Main Si
QLD KINGS HIGHWAY Waltham,MA 02451-1601 .
LATEST UPDATE
7/1112022M
—Fax:781-899-2072
OWNER
Derek Pick
Abbreviated Quote Report-Customer Pricing
QUOTE NAME PROJECT NAME QUOTE NUMBER CUSTOMER POP TRADE ID
Cicreto JEFF WRAGG 2198080
ORDER NOTES: DELIVERY NOTES:
Itt_rn .ft Operation Location Unit Price Ext.Price
100 1 AA None Assigned $478.19 $478.19
•
RO Size=26 1/8"x 44 7/8" Unit Size=25 518"x 44 718"
ib----- '
TW2036,Unit,400 Series Double-Hung,Equal Sash,Installation Flange,White Exterior Frame,White Exterior Sash/Panel,Pine
vo/White-Painted Interior Frame,Pine wlWhite-Painted Interior Sash/Panel,AA,Dual Pane Low-E4 Standard Argon Fill Finelight
Grilles-Setween-the-Glass Division,Standard Grille Alignment,3 Wide,2 High,Colonial Pattern,White,w/WhIte,3/4°Grille Bar,
Stainless Glass/Grille Spacer,Traditional,i Sash Locks White(Factory Applied),WhitoJamb Liner,White,Full Screen,Aluminum
•
insect Screen 1.,400 Series Double-Hung,TYV2036 Full Screen Aluminum White PN:1610163
Unit 4 U-Factor SHGC ENERGY STAR Clear Opening/Unit d Width Height Area(Sq.A) Comments:
........—_—_—_—..........
Al 0.3 0.28 NO Al 21.8750 17.7500 2.71000
Quote fir:2198080 Print Date: 7/11/2022 1125,26 AM UTC All Images Viewed from Exterior Page 1 of 3
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SECriON 5: CONSTRUCTION SERVICES
S.1.. Construction Supervisor License(CSL)
i .
1 License Number 7---,xpiration.Date
Name of CSL Raider , .1
List CSL Type(see below)
1 No.and Street TYPe i D e.seription
r- ti 1 Unrestricted(Buildings up to 35,0Q,zu,II)
I R P_esnicted let.%Family Dwellinq
Ciryfrown,Sul:,ZIP
Ni lvfasonri —1
I RC Roofing Cvenng
1 WS i Window and Sidisic
r---- ,
SF i Solid Fuel Burnin7 Appliances
- - - . ' 'Appliances
: , insulation
--- ,
Telephone Email address 1 D Demolition
5.2 Registered Home Improve.ment Contractor(mg ..,,,
1 —1_11
1
I liiC Regigraiori Namber Expiration Date
13.1C Company Name or ZUC Registrant Name
. ___—
No.and Street 1 -
i Email address
City/Town Sf-ar' aP Teleolione t i
SECTION 6:WORKERS'COHPENSATION INSURANCE AFFIDAVIT(NI.G.L.c. 152.§ 25C(6)) I Workers Compensation Insurance aMdavit roust be completed and submitted with this application. Failure to provide l
this affida-rit will result in the denial of the Issuance of me buildMg permit.
Signed Affidavit An-ached? Yes .....„...0 No„,....-..0
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SECTION 7a:OWNER AUTHOltrZATIONTO BE COMPLETEDWHEN-
' OWNERS AGENT OR CONTRACTOR.APPLIES FOR BUILDING PERMIT.
--f (Nrs , .
--, 1,as Owner of the subject proper,r) hereby authorat ,_,,i e-1--1- ii,..)r .Cr_0-- _......_to act on my behalf,in all mattms relative to work authorized hy this buildine g pt-mit li appcaton,
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Print Ow s., ame(Tilecconic Signature Oat
.._. ..._
SECTION lb:OWNER1,OR AUTHORIZED AGENT DECLARATION i
---1
By entering toy name below,i hereby attest tinder the pains and penair:es of perjury that all of the taformarica
contained in this application is true and accurate to the best of my knowledge and tuiderstandins„
_
c:2(1
ci1/4,.
Print Owner s or A.urhorized A_gett's Name(Electronic Sigiamm) Date
NOTES' ' 1 ,
_ __
1. An Owner who obtains a building permit to dc.,hiVrier own work,or an owner who hires an=registered contractor I i
,
(not registered to the Home Improvement Contractor(HiC)Progam),will nor have access to the arbitration
program or guaranty funclunder IVI.G.L,e.142.A.Other important information on the HIC Program can be four...i at ! .
vrAr.,7e,mass.tzav tact Info:TT-do:on the C-'outruction SuperYbor License can be found at-.vww.raass.zovidos ;
2. Whet.substantial work is planned,7revide the i,....fon.na,lon below:
Total floor area(sq.ft.) ",in.clrrlirta garage„Ein.ished basement/aft s.dech'or porch)
Gross living area(sq.ft.) Habitable room soczt :
Number of fireptaces Number of bedrooms _ t
Number of bathrooms Number of banoths
I Type of heating systetn Number of decks!conches *, I
Type of cooling sys-tta Enclosed Open
, .
3. "Total Project Square Footage"may be substituted.for'Total Project Cost"
,
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