HomeMy WebLinkAboutBLD-23-000809 ONE & TWO FAMILY ONLY- BUILDING PERMIT
"` Town of Yarmouth Building Department o .....y
RE C E I V E 0 1146 Route 28,South Yarmouth,MA 02664-4492 -'
—_ ' `508-398-2231 ext. 1261 Fax 508-398-0836 ,�c,�
` AUG 16 29 Massachusetts State Building Code,780 CMR �` j ,,� t
QQ �'
Bw ding l ernzit Application To Construct, Repair, Renovate Or Demolish
l a One-or Two-Family Dwelling ''
BUIL DING DEPARTMENT i o
This Section For Official Use Only
Building Permit Number: Z3--t) j I Date Applied:
vial
Buiiding�ffcial rintNamej '/':-��-�
gn tore Date
SECTIO 1:SITE INFORMATION
11 PrciLloperty Address: 1.2 Assessors Map&Parcel Numbers
err y Rvrevupe W. `jarutnov IL, 53
1.l a Is this an accepted street?yes )( no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
e.-ZS Si'►n1t F.A.A,L4 R~er. 1 z, I sS 13 S
Zoning District Proposed Use J Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
3O 2a i /.S - 24. Z Zo ILIAC 3 2.9 -
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private 0 Zone: V E Outside Flood Zone?
t A E. Check if yes❑ Municipal 0 On site disposal system X
SECTION 2: PROPERTY OWNERSHIP'
�/
2. Owner'of Record:
Klc\ � A.n.cd J
Rs.r aavr, )kii2 WeS}- 1Gtr-,AnaJ-t-ll ►iAA 02,672
Name(Print) City,State,ZIP i
l -1 Etrry Rvre. 630- 62,9 -9$I g Y'wk +e a Anner', feck, c f
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction 0 I Existing Building,K Owner-Occupied;E I Repairs(s),q I Alteration(s) 0 I Addition 0
Demolition ❑ I Accessory Bldg. 0 Number of Units 1 Other 0 Specify:
Brief Description of Proposed Work2: e e r+ t• _
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs:
(Labor and Materials) OfficialUse Only
I.Building $ 3 U D<,O — I. Building Permit Fee:S SU Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
�.Plumbing - 0 Total Project Cost3(Item 6)x multiplier . x
$ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
6.Total Project Cost: $ 3 o 000 Check No. Check Amount: Cash Amount:
10 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
cj ' Ilh3"Lt /Lf,6/Zo2_ -
S Cc is,' Sf'e r License Number
Name of CSL Holder Expiration ate
1' \i\i e'L i tI e✓+-v_y� ' c-,, r List CSL Type(see below)
/ No.and Street 4c�1 Type Description
,/ l (Buildings up to 35,000 cu.#t.)
d ��a i1 Z U Unrestricted
City/Town,State,ZIP / R Restricted 1&2 Family Dwelling
114 Masonry
RC Roofing Covering
Lt�� v t WS Window and Siding
iti t f 20iy SF Solid Fuel Burning Appliances
0itY -SAS-- p zZ C. 9 j. I . (.. �
1 I Insulation
Telephone `'�
Email address D J Demolition
5.2 Registered Home Improvement Contractor(HIC)
�hyfL,tno1 gJ� Pa�ht- >,1/4.c I9I7-'7- 1- 0�J3,AD24
Name
HIC Registration Number Expiration Date
HIC Company Nude or HIC Registrant Na
( I VVedgqevinere R' o& al arty 1 int lo., .e.jytt- zoo.' ,l
No.and,Street J
W 0.r•rttb•itil w1u OZb�3 egS-SOS-t'0 ZZ Email address
City/Town,State,ZIP Telephone 004.11.Cow
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 X
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 A 11\J'�i fj g1/4lf F 1 w}. L L C
to act on my behalf,in all matters relative to work authorized by this building permit application.
ct
I`1G\f\o‘rA lAiki-4-Q, / aazL
Print Owner's Name(Electronic Signature)
ate
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
•
By entering my name below,I hereby attest under the •ains and penalties of perjury that all of the information
contained in this application is true and a urate to t •-st my knowledge and understanding.
Pthy iln Iievi Bvt T'.1%►AA- c.oir 2 1Zb2Z
Print Owner's or Authorized Agent's Name(E etronic Sign. a)
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.gov/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"
i� „._\ • The Commonwealth of Massachusetts
`' J, Department of Industrial Accidents
`.jos= 1 Congress Street, Suite 100
`=i={= Boston,MA 02114-2017
a www.mass.Q v
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A Iicant Information
Name (Business/Organization/Individual): PtPlease Print Leaibl
Address: 1 I We ewteel, Roaof
City/State/Zip: 1Nes+ YArirt,.acf MP, Can Phone#: S'1S-SOS
rDOZL
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑1 am a employer with
employees(full and/or part-time).*
2.C4 I am a sole proprietor or partnership and have no employees working for me in 7' El New construction
any capacity.[No workers'comp. insurance required.] 8. ► Remodeling
3.0 I am a homeowner doing all work myself(No workers'camp.insurance required.]t 9. Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees, 11.Q Electrical repairs or additions
12.0Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
13.0 Roof repairs
These sub-contractors have employees and have workers'comp. insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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 ail 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 copy of the workers' compensation policy declaration page(showing he policy number and expiration date).
Failure to secure coverage as required under MGL c. I52,§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 verifi anon.
1 do hereby c tify i d r 1 e pains and penalties of perjuzy that the information provided above is true and correct
Signature:
Phone#: - Date: 0 2 021-
05- e0ZZ
Official use only. Do not write in this area,to be completed by city or town official
City or Town:
Issuing Permit/License#
b Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Ins ector
6.Other
A
Contact Person:
Phone#:
TOWN OF YARMOUTH
o
BUILDING DEPARTMENT
u 1146 Route 28, South Yarmouth,MA 02664 50 -S 398 2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION: w �k� Res(Cte1C-e IT-{ terry Ptve, Wes+ Yo►r,Mou 11,
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" CrI. . cA IN 14e.__. Ca3D (c34) q�lc
NAME HOME PHONE WORK PHONE
PRESENT MAIL NTG ADDRESS I q`I g,e rr Ave vie
VJesi Yar`gnovtl Amot d' t4q?
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 building 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 that he/ she understands the Town of Yarmouth Building Department
minimum inspection procedures and re ' eats and that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OPriCIAL
INSURANCE COVERAGE:
I have a current liabiljty insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes/ No
If you have checked ves,please 'ndicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER' INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 oft .�ass. 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:horfieownrlicexernp
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-223;1 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 icH Ztrcj Avevti,,€, \JVeS4 Yar-nnavll•, AAA02b 3
Work Address
Is to be disposed of oat the following location: v.,h of Yar 144 a v 11L1 LA IN-cA If
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
6/B/Z0zZ
ignature f Application Date
Permit No.
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