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BLD-22-006319
R E C E I V [DEL & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Departmentk APR 26 2022 1146 Route 28, South Yarmouth,MA 02664-4492 ,Ar 508039t-.2N 1 ext. 1261 Fax 508-398-0836 ' Massachusetts State Building Code, 780 CMR By:BUILDING DEPARTM uzich.g Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only p,U,2Z Building Permit Number: -ob(O3I q Date Applie • 11 1 SQ1115 Building Official(Print Name) Si ature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers Si F3-caW1c� es -1 V2- ZZ2- 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 7 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? Municipal 0 On site disposal system Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: L 156 5t'i t-"C" L c UtS LDY6 net oi-bow o Yh o t f ct Name(Print) City,State,ZIP I(4 bo Ko A-i, &j13-S31-79Z3 LST/Aeowl St. k No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building Owner-Occupied NUL Repairs(s)Iitj AIteration(s)1t. Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: g ern 6✓v .O il) 2OO(Y1 W 10 bOutl S/ 6Os1 C AU 0 7?c' t-cc W/u GtA). .t'c rric J c, t-X Sr1 A I i /%I Jib R,t,13or 70 evsrV PG Sr z.5 + S 106cS • Sorio1 t POSF5 l'OVA 5 4- R.Al c.S. `satins "'CD kinftt0"PISS i 5 ". — N du) fr2. . SECTION 4: ESTIMATED CONSTRUCTION COSTS. par4c14')4 +"iS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 5®O00 1. Building Permit Fee:$ 1 c0 Indicate how fee is determined: 2.Electrical $ I 0 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x mu tiplier x . 3.Plumbing $ 2. Other Fees: $ 3S C Zo Co ( Y �' 4.Mechanical (HVAC) $ ,/ List: GY_ hCtl‘')\ 5.Mechanical (Fire $ Suppression) ./ Total All Fees: $ v 6.Total Project Cost: $ 5-007 )� Check No. Check Amount: Cash t: 0 Paid in Full 0 Outstanding Balance D I r L SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �- l /ay3a 07b 763 S Jao License Number Expiration Date Name of CSL Holder —12 p/ t CO,! IC 1 _ UL List CSL Type(see below) No.and Street 1V fv Type Description W. VA ibrAdV114 Unrestricted(Buildings up to 35,000 cu.ft.) City/Town, tate,ZIP 1P I R Restricted 1&2 Family Dwelling M Masonry • RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances r z.€4 4jT►flkk,. 'Ceo Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ) I,rA:.L W�� ��xtllS ISk �'UtC jX J 10 eg57 I/'/`Staedon HIC Company Name or HIC Registr t Name HIC Registration Number Expiration Date o.and tr �t !T►tI C 14- -0 203 ."6 fs-24q 5 7- Email address City/Town, 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 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 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: OWNER1 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. 57?>vi ,1 -r /II r 12z 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.cov/oca Information on the Construction Supervisor License can be found at www.mass.cov/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" • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ^�..� www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILEtD WITH THE PERMITTING AUTHORITY. Applicant Information f Please Print Legibly Name (Business/Organization/Individual): ,5 i J I/-r iT-C. _NO LaJI S Mk/84 IL?3S Address: 72 P/NC Cc J City/State/Zip: UV ./A->lZiYIIUI,C�!-II �� `7 Phone : 66%)- Zvi—�z.' Are you an employer?Check the appropriate box: Type of project (required): T. I am a employer with employees(full and/or part-time).* 7. ❑New construction tam a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. �:lZemodeling 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. demolition 4. 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 11.7 Electrical repairs or additions proprietors with no employees. 5.0 I 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.* 1 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: 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif nder the p ins zd penalties of perjury that the information provided above is true and correct. Signature: Date: 17111iz Phone#: 5'0 c‹— Z 59 - 7 �Z Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License r Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: TOWN OF YARMOUTH • r, 0 BUILDING DEPARTMENT - 'i`R`+ 1146 Route 28, South Yarmouth,MA 02664 ccA " "„� z�ra 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 2 Work Address Is to be disposed of at the following location: 20 f?-- ( LNLP' �w�mps-t2. Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. L (/I 12-2-- ignature of Application Date Permit No. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 165119 01/06/2024 STEVEN HETZEL D/B/A LEWIS BAY BUILDERS STEVEN HETZEL Y 72 PINE CONE DR. ��, �aG�� W.YARMOUTH,MA 02673 Undersecretary Commonwealth of Massachusetts IPDivision of Professional Licensure Board of Building Regulations and Standards Consftimut' Ili i$rvisor CS-1 04384 spires:07/27/2023 STEVEN L HETZEL 72 PINE CONE DR WEST YARMOUTH MA 02673 . • Commissioner a a '. 17CemcJtca .. . 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Z 4,4•44k.i.o.: OS (5- .. °Z.-- Sears, Tim From: Sears, Tim Sent: Friday, June 3, 2022 8:24 AM To: Steve Hetzel Subject: 21 Berwick Steve, I have reviewed your updated plans and there needs to be more detailed framing information, post connections, lateral brackets etc. the footings are also required to be a minimum of 12" Please update your plans and submit for review I imothy Sears CBO Deputy Building Commissioner I own of Yarmouth 508-398-2231 Ext. 1259 mailto:tsears@varmouth.ma.us J 'c)Ac'(\s �r c� ;�;�55 c, .l Sears, Tim From: Sears, Tim Sent: Friday, May 6., 2022 10:15 AM To: Steve Hetzel Cc: Slack, Christine; Hudson, Heidi;Water Department Subject: 21 Berwick Rd Attachments: work in flood zone packet.PDF Steve, I have r viewed your application for renovations/deck replacement and there are some items needed. . Health Department sign off ‘,.1124Vater Department sign off 3. Conservation sign off 2 copies of framing/footing plans for deck This property is in a flood zone, packet is attached Please submit these items for review This email is considered a written denial of your permit application per Section 105.3.1 of the Massachusetts State Building Code. Section 105.3.2 states in part that "an application for a permit for any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been pursued in good faith" You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100,within 45 days of this notice. Timothy Sears C8 Deputy Building Commissioner own of Yarmouth 53--3 ..223 Ext., 1259 ma.ilto:tsears y,a,rmouth.ma.us 1 of Y ,„p Conservation Office �c Town of Yarmouth -3 _ k•ra tet,. i.ma.us ° y `! Conservation Commission co �onS �'4---- , , mMissionvat. Building Permit Sign-off Application TO BE FILLED OUT BY BUILDING PERMIT APPLICA jx),), BuildingSite Location: 2-f W tC _ (' O kt✓ H:::::: Map # Lot(s) # Property Owner: L S cps(VT Lau tS Date filed: 51Z5(zZ *Applicant: 9"M111 t cZ f1ç L.c C' lam( -gotc_�eK-S Applicant Address: 2i.5 CO'YrltA cilt eArTI (Ai kli Oil ii '31) AA(oh)h5 O'2._(.oa ( Email: sU--EEL 2-@_ I111 Cc>'7t Telephone: socz? Z5-q c s2- Please Note:By submitting this application the applicant grants permission to the Conservation Office to enter the location to conduct a site visit(if needed). Proposed Project Description: ( 0 Lt.)r t-i 01 S S J'cJ P_Bayo Site Plan Title/Date: c-tC— Z( 2 A 2Z TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the proposed project require a permit? v Refer to: SE83- or DOA permit Comments from Conservation Commission: Approved Conditionally Approved Rejected (4)enW-�� �7S.e& Ltiorv\ ,-e.v-tS4"1 J - o-f1'► 5 / ô Ki2AA) O✓ mil --ITJ64CS. Conservation Commission Sign-off Signature: �'\ +�'v Date: 5 (2 E( 22 *TO APPLICANT: All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each day, the area shall be clean and no debris shall be in the Resource Area. If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed, along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site during construction. Please refer to the Order of Conditions for further details. Building Attributes Building Photo Field Description 1 Cape Cod (Style: } y Model Residential IGrade: 1 Average+20 , . i Stories: 11.75 I s Occupancy 1 z 1 Exterior Wall 1 I Wood Shingle i -- ,> , ' I 1,Exterior Wall 2 I I -- I Roof Structure: I Gable/Hip Roof Cover 1 Asph/F Gls/Cmp iiii D alUSheet (https:!/images.vgsi.com/photos2lYarmouthMAPhotos//\00\03\26\OO.jpg) Interior Wall 1 MN Interior Wall 2 Building Layout 3 Interior Fir 1 1 Hardwood FSP WOK 10 I Interior Fir 2 1 14 is 1 24 WDK t4 4 4 I Heat Fuel 1 Gas [ WDxt2 4 12 44` WDK(X2) 24 14 k ' 13: 12 16 CTH Heat Type: 1 Hot Water HAS uOR nT 22 F AC Type: i None 16 1618 I j TQS I Total Bedrooms: ?3 Bedrooms 26 vaM 12 1 I 4 /4 I Total Bthrms: i 2 10 } Total Half Baths: I 1 41 0 i Lens9 21 UBM Total Xtra Fixtrs: (ParcelSketch.ashx?pid=5208.bid=553) I Total Rooms: I I Legend J i -- I I Building Sub Areas(sq ft) g 1 Bath Style: I Average I I I 1 Gross Living (Kitchen Style: 1 Modern 1 I Code Description Area 1 Area I ?Num Kitchens `01 1 BAS I First Floor { 1,276 1,276 j i I I I I Cndtn I I I TQS Three Quarter Story 1,066 800 Num Park 4 CTH I Cathedral Cing 192 t)1 1 [Fireplaces ! j I FGR E Garage 3081 0 I I Fndtn Cndtn 1 I FSP I Porch,Screen,Finished 168 I 0 I Basement i UAT I Attic,Unfinished 308 I 01 1 f 1 UBM !Basement,Unfinished s 1,084 01 I I WDK I Deck,Wood 1 592 I 0 I NAY 2 5 2022 4,994 1 2,076 HEALTH DEPT. Extra Features Legend Extra Features — I Code ' Description Size Value Bldg# 1 u 1.00 UNITS $2,400 1 ? FPL3 12 STORY CHIM _ I 1.00 UNITS $0 1 { IEOS 1 End Outs Shwr i DEALER NAME COUNTERTOP ORDER DATER PAGE JOB a DATE WANTED DESIGNER SHIP TO - —j PRODUCT CORE MATERIAL BACKSPLASH TYPE TYPE DECK COLOR ACCENT COLOR EDGE MATERIAL EDGE FINISH SHAPE C7 V ' r 13-4 V(i 00 -� -7 MAY 2 5 2022 HEALTH DEPT. 1-800-336-3633 MA FAX 1-800-982-5573 NE KOUNTERWERK2j DIRECT 1-508-482-93777 MANUFACTUPEPS OF CUSTOM COUNTEFTOPS ST OESIGN TPd 1 Ill DEALER NAME COUNTERTOP ORDER DATER PAGE JOB# DATE WANTED DESIGNER SHIPTO P} 1( . Y { ' PRODUCT CORE MATERIAL BACKSPLASH TYPE TYPE DECK COLOR ACCENT COLOR EDGE MATERIAL EDGE FINISH SHAPE 0 $ il -.1. (' cc x dr _ til <. to cn -INS tkl it 0 Rls©L YviE D N MAY 2 5 2022 , HEALTH DEPT. s 0 1 CIS v� I 0 ' 550 6 l .©a r 1-800-982-5573 N E FAX 1-508-482-91 [ç_o L TN s'EMR COUNW E R K j DIRECT 1-508-482-937 IMAM/PACNE 1-800-982-5573 �1 77 O S BY DESIGN TPd 1 Ill AVN /8'1*sYA:44i-N, , WATER DEPARTMENT • '4" . k ,--±.,74" 'rarrr . th, Hif„T!,w1t- • I>iv AkIt;' BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OFF TRANSMITTAL FORM BUILDING SITE LOCATION! ZBc1L (40( 0-0 A---& PROPOSED WORK: 7° Ce-4C- go'Ourc:elvioN - SA-NIC Fool-Pa,/ r ) APPLICANT: -'t-r•trZakLJ /C -1-7.-*C-046,t) (.0%)-)1& B•Ai ADDRESS: 2.(0 S cowl 01 Li col (Ai to.i. (4 ( 141(4TIA cetocil TELPIIONE: 2--Sct RESIDENTIAL AND OR COMMERCIAL BUILDING Water I)cpartments Determines Compliance of Water.Availabilit). and or existing location Engineering Department: Determines Compliance for Parking and Drainatic Conser.ation Commission: Determines Compliance to Wetlands Act: c. If Ions) border any type of wetlands, streams, ponds. ri%as. ocean, bogs, boys, marshland, ETCI . lealth Department: Determines 'ompliance to State and Town Regulations, i.e. requirements tor Septat.te Disposal and other Public Health Activites lire Department: Determines Compliance to State and [own Requirements for Personal Satety, Property Protections. i.e. Smoke Detectors, Sprinkler Systems,ete 1Z 2-- ANT SIGNATURE RAFE OFFICE USE: COMMENTS ON PERMIT APPROVAL OR DENI ROT OrAk , nA C-12-1,12-4>2 2_ REVIENED %%ATER DIVISION(SI(.NATURE) ATE tit/irk Building Attributes Building Photo Field Description Style: Cape Cod Model Residential r L�4• Grade: Average.«20 .' Stones: 1.75 Occupancy 1 y Exterior Wall 1 Wood Shingle i i 1� x"� -- Exterior Wall 2 Roof Structure: Gable/Hip Roof Cover Asph/F GlslCmp 0, Interior Wall 1 Drywall/Sheet {hitps:IHmages.vgsi.comtphoto521YarmauthMAPhotosllt00l03t26100.jpg) Interior Wail 2 Building Layout Interior Fir 1 Hardwood Interior Fir 2 Heat Fuel Gas Heat Type: Hot Water is Oro AC Type None "y. Total Bedrooms; RED°. 3 Bedrooms xa say Total Bthrms: 2 a Total Halt Baths: 1 AI 0 A 2 Total Xtra Fixtrs: s (ParcelSketch,ashx?pid=520&bid=553) Total Rooms: Bath Style. Average Building Sub-Areas(sq ft) Legend Gross Living Style: Modern Code Description Area Area Num Kitchens 01 BAS First Floor 1,276 1,2/6 Cndtn t 0S Three Quarter Story 1,066 800 Num Park CTH Cathedral Cing 192 0 Fireplaces FGR Garage 308 0 Endtn Cndtn FSP Porch,Screen,Finished 168 0 Basement UAT Attic,Unfinished 308 0 UBIVI Basement,Unfinished 1.084 0 L. WDK Deck,Wood 592 0 4,994 2,076 k Extra Features Extra Features gend Code Description Size Value Bldg# FPL3 2 STORY CHtM 1.00 UNITS $2,400 1 EOS End.Outs Shwr 1.00 UNITS $0 1 E* C P, SERVICE NO, fa 7 .4.77 NAME67( 13780-48 �'"� Dr Andre St Louis iew, b-30-94 �y t STREET c21 ,eloc k. j k t /j f VILLAGE 455 ,oeM( j4 • • METER NO« 1/2 14 / ", 3 J I/4 6/ / I' fh3,� i i Li4 kl ! a 1 1 . Z\ 1 C§ lizz- tr 1 -ee:c i'l) Ag?..,›d • 1 1 i t 1 °F \; TOWN OF YARMOUTH t5.i. r �° BUILDING DEPARTMENT `t An,���_��_ 1146 Route 28, South Yarmouth, MA 02664 `` -.- '' Telephone 508-398-2231 ext. 1261 Fax 508-398-0836 Contractor's Affidavit: Substantial Improvement or Repair of Substantial Damage Property Address: Z.k uoitc _- tZoitb Parcel ID Number: 2-J 2,71Z Owner's Name: LI S b 5 7 ( Lou/S Contractor: 5 E1L,1 (4 1 zC - 61 ) Cjf S 1 BV f ��S Contractor's License Number: CS—'0 q?,SPCI Date of Contractor's Estimate: 6(2 '5I Zv I hereby attest that I have personally inspected the building located at the above-referenced address by the nature and extent of the work requested by the owner, including all improvements, rehabilitation, remodeling, repairs, additions, and any other form of improvement. At the request of the owner, I have prepared a cost estimate for all of the improvement work requested by the owner and the cost estimate includes, at a minimum, the cost elements identified by the Town of Yarmouth that are appropriate for the nature of the work. If the work is repair of damage, I have prepared a cost estimate to repair the building to its pre-damage condition. I acknowledge that if, during the course of construction, the owner requests more work or modification of the work described in the application,that a revised cost estimate must be provided to the Town of Yarmouth, which will re-evaluate its comparison of the cost of work to the market value of the building to determine if the work is substantial improvement. Such re- evaluation may require revision of the permit and may require revision of the permit and may subject the property to additional requirements. I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals that I have made or authorized repairs or improvements that if inspection of the property reveals that I have made or authorized repairs or improvements that were not included in the description of work and the cost estimate for that work that were basis for issuance of a permit. Contractor's Signature [‘+"-‘S Date: 5125( ZZ Notarized: r' • TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 Telephone 508-398-2231 ext. 1261 Fax 508-398-0836 Owner's Affidavit: Substantial Improvement or Repair of Substantial Damage Property Address: ZJ 6 sW cam- 4:*b Parcel ID Number: z_/ 20- Owner's Name: L1 lji✓ 5AI 1J( L,COtA(s 9,L'3-- 631 — `JSz3 Owner's Address/Phone: (g 1,UR tiAltA ( &M I_O►JG M om KAA. c2 )6 40 Contractor: 5T Va Z6'L(N i� L I S 31 3Utl-ll Contractor's License Number: '-' !Ott 3gq Date of contractor's Estimate: v /25/27. I hereby attest that the description included in the permit application for work on the existing building all improvements, rehabilitation, remodeling, repairs, additions, and other forms of improvement. I further attest that I requested the above-identified contractor to prepare a cost estimate for all of the work, including the contractor's overhead and profit. I acknowledge that if, during the course of construction, I decided to add more work or to modify the work described, that the Town of Yarmouth will re-evaluate its comparison of the cost of work to the market value of the building to determine if the work is substantial improvement. Such re- evaluation may require revision of the permit and may subject the property to additional requirements. I also understand that I am subject to enforcement action and/or fines if inspection of the property reveals that I have or authorized repairs or improvements that were not included in the description of work, and the cost estimate for that work that were basis for issuance of a permit. Owner's Signature: Date: g/212Z Notarized: Jae • Substantial Improvement Worksheet for Floodplain Construction (for reconstruction,rehabilitation,addition,or other improvements,and repair of damage from any cause) Property Owner: set/N T L,Q UI Address: ICI( k0(tis W • Vfl'etY1o,c 1 OV p73 Permit No.: Location: Description of improvements: Q't✓(A.)01Ll.C. tom. Wei k+ ''Atz I m Present Market Value•of structure.ONLY{market appraisal or adjusted. assessed value BEFORE improvemenf or damaged; before the damage occurred):mot Including land value : $ 3 ao Cost Of lrxtprovement Actuat Lost:af the $ i'40I 8 *include vole nteerlabor and donated su *' • Ratio Cost of Improvement(or Cost to Repair) �fl0 10 % Market Value If ratio is 50 percent or greater(Substantial Improvement),entire structure including the existing building must be elevated to the base flood elevation(BFE)and all other aspects brought into compliance. Important Notes: 1. Review cost estimates to ensure that all appropriate costs are included or excluded. 2. If a residential pre-FIRM building is determined to be substantially improved, it must be elevated to or above the BFE. If a non-residential pre-FIRM building is substantially improved,it must be elevated or dry floodproofed to the BFE. 3. Proposals to repair damage from any cause must be analyzed using the formula shown above. 4. Any proposed improvements or repairs to a post-FIRM building must be evaluated to ensure that the improvements or repairs comply with floodplain management regulations and to ensure that the improvements or repairs do not alter any aspect of the building that would make it non-compliant. 5. Alterations to and repairs of designated historic structures may be granted a variance or be exempt under the substantial improvement definition)provided the work will not preclude continued designation as a'historic structure.` 6. Any costs associated with directly correcting health,sanitary,and safety code violations may be excluded from the cost of improvement. The violation must have been officially cited prior to submission of the permit application. Determination completed by: Date: 5 12�'j 1 22_ TOWN 4F VR11Iou TIC 1146 Route 28 'ai i oath, MA 02664 508-3 8-2231� ex ! 6I lax 508-338-0836 Office of the Building comnusstoner + � Y" gip FINAL COST AFFIDVIT FOR WORK IN FEMA FLOOD ZONE To the Building Commissioner, In accordance with 780 CMR Section 109 of the Massachusetts State Building Code, the total estimated cost of construction, including all related costs* of the building at Z.( (CL/Zc'71t P and constructed, reconstructed, altered,repaired, or extended under building permit no. amounts to $ 14 4 000 I, S1.- -t,ceL C`Es—T C_ ,being referred to as the owner/agent identified below,do solemnly swear that the statements made herein are strictly true, correct and made in good faith *Related construction costs include all work done with or concurrently with the work contemplated by the building permit including construction, reconstruction, repairs, demolition, HVAC work, etc. Furnishings and portable equipment are not part of the total construction costs. 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