HomeMy WebLinkAboutBLDR-23-12959- ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department + , ."y 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 e'
a One-or Two-Family Dwelling
This Secttiion For Official Use Only
Building Permit Number: Z ""17-("a Date Applied: -'
Building Official(Print Name) ignature Date
SECTION 1:SITE INFORMATION OCT 1 3 2fl 3 .
1.1 Property Address: 1.2 Assessors Map&Parcel Numberd _
Ifs rier'M MA;1'1 sfrrr4 s. n.i*ih BUILDING DEPAR—MENT
1.1 a Is this an accepted street?yes ✓e no Map Number Parcel Nur h ---
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 I 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: J
Zone: _ Outside Flood Zone?
Public 0 Private 0 Check if yesO Municipal 0 On site disposal system CI
SECTION 2: PROPERTY OWNERSHIP`
2,,1 Owner'of Record:
)461,k L oc,.s-c sar41. Xarr.4:5Jf1% ttka. Oa 64'f
Name(Print) City,State,ZIP
/Yf norit rnc,,irl S-iretf 604-4s-s--1711 Hr sears 1 @ nsm .tom
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building fiVi-Owner-Occupied 0 I Repairs(s) el Alteration(s) 0 I Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': Mys t was 904AI caw.% i 9vic "h r l✓ed, P# rr
Tvi$4 hove car gad D..tn da+t by 4,,.1/40Amer awfrver 4e►r. Z,et a6c.-79
sib t6or 40 r.•.►:sk
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: \‘,12 L ccial Use Only
(Labor and Materials)
1.Building $ GQ Opp 1. Building Permit Fee: 4< Indicate how fee is determined:
2.Electrical $ , f i§kStandard City/Town Application Fee
�' Opo
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ g,0400 2. Other Fees: $
.
4.Mechanical (HVAC) $ List: 357 46 0.4tOto
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount
6.Total Project Cost: $ (60,Ooo 0 Paid in Full ! Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS-lard kz-s GJ• Bare 4e. License number e- a.4
Number Expiration Date
Name o CSL Holder
/or N4".der• c
List CSL Type(see below) V
No,and Street Type Description
Neiar.,� 044 U Unrestricted(Buildings up to 35,000 cu.ft.)
City Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC I Roofing Covering
WS Window and Siding
L SF Solid Fuel Burning Appliances
SnY ?4? `1 a 1 JurL#fG frOy/ ;1.Can. I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
ke.s $ur e Plc 2609 2 tf a..C!"'2HIC Company Name or HIC Registrant Name HIC Regirstlration Number Expiration Date
No.and Street Email a dress
[few-F.rustk tea d dc• 5 a teY-3L?412%
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 0 No .❑
•
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WFIEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize DoLoc k4 S
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: 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.
ld//
Print Owner or Authorized Agent's Name( 4ectsdnic Signature) Date
NOTES: •
I. 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.eov/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.) 7$0 (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) 7a0 Habitable room count
Number of fireplaces Number of bedrooms a
Number of bathrooms I Number of half/baths Q
Type of heating system Iffea4 Pow% Number of decks/porches
Type of cooling system mi„; Sp;f Enclosed Open S.—
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
aa; !-= 1 Congress Street, Suite 100
"i Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): C rreHe /&e% &i/eJ,1i c;:1J 1�t,�+acac-i,1c/
Address: //G 'p/r�n ie'ys �c:n e
City/State/Zip: 1wr14 tie j`'ic. Off/j,1 Phone #: O — S6 7 _t,/1
Are you an employer?Check the appropriate box:
Type of project(required):
l.0 l am a employer with employees(full and/or part-time)."
7. ❑New construction
2. zm a sole proprietor or partnership and have no employees working for me in 8 ,�
any capacity.[No workers'comp. insurance required.] �v {entode(in� •
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. E. Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 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. 12.0Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insance.t 1 Roof repairs
w
6.0 We are a corporation and its officers have exercised their right of exemption per,MIGL c. 14.❑Other
152,§1(4),and we have no employees. [No workers'comp.insurance required.]
*Any applicant that checks box ml must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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: /if J cicitk 1146 h �f-ree f City/State/Zip: yutme.t/ ('iA 0: 4G`f
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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sisnature:' ) Date: /6 '// 3
Phone#: .5 O 36 7 —6/.2l
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
§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 //c 5'-free
Work Address
Is to be disposed of oat the following location: ) .-i i:-t4, zt,,t)
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
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Signature of Application Date
Permit No.
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Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Cons iortIS , rvisor
CS-115452 Expires:06/03/2024
DOUGLAS W SURETTE
105 HAMDENCIRCLE 44
HYANNIS MA 02601
ly �y 5+�, b
Commissioner (letAf,. .