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Public 1i' Private❑ Check if yes❑ Municipal 0 On site disposal system aC SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: sc, �q Name nnnt City,State,ZIP ` 1 OSa 6Vo-1-1 ,vvc ft t$ No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: "fe to ce�e.,Sm.� C`b to SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ 3 0 Total Project Cost em x multiplier . x 3.Plumbing $ 2. Other Fees: $ �/.�� COV 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $as,OD 0 Paid in Full 0 Outstanding Balance Due: , 1 SECTION 5: 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 35,000 cu.ft.) City/Town,State,ZIP R Restricted I&2 Family Dwelling iv I 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(HIC) HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date No.and Street 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 0 No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as 0 A.- of the subject property,hereby authorize ac on .y beha 11 matters relative to work authorized by this building permit application. yr Print 0 ,er's •.. - lectronic i 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. 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned provide the information below: Total floor area(sq.ft.) o� ty s (including garage, finished basement/attics,decks or porch) Gross living area(sq.ft.) ' Habitable room count Number of fireplaces "3. Number of bedrooms °'r Number of bathrooms Number of half/baths ..A '' 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 4111—F Department oflndustrialAccidents s ; 1 Congress Street, Suite 100 • Boston, MA 02114-2017 r'y'�� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information � Please Print Le4ibl ^ Name (Business/Organization/Individual): ,��n^ Address: '�, L 1 1 �_�b n rl �• City/State/Zip: �, q +�.. 9 one d`S'Mes..J one #: Are you an employer?Check the appropriate box: t am a employer with Type of project(required): I. ❑ employees(full and/or part-time).* 2 l— m a sole proprietor or partnership and have no employees working for me in 7. ❑New constdelinruCtlOn any capacity.[No workers'comp. insurance required.] 8• [] Remoeling • TE2-I-ern a homeowner doing all work myself. [No workers'comp. 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" tilding addition ensure that all contractors either have workers'compensation insurance or are sole 11. 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, 1 ❑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. 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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 pol cy 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 cert. under and penalties of perjury that the information provided above is true and correct. Signature: Date: q l a Phone#: !` 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 ct i BUILIDING DEPARTMENT MATTACttECSE/�0� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: 021\sk\Y-- L. I Qo.Z cc YWA'10,04t) NAME , STREET ADDRESS SECTION OF TOWN "HOMROWNER" �l'`n-. 1�tMv� -e61. )Sa etbq C 1 NAME HOME PHON WORK HONE PRESENT MAILING ADDRESS �. t Vc Dr PiSMv Lik CITY OR TOWN STA'1E 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 ui nts and that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATU APPROVAL OF BUILDING OF141C INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. 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:homeownrlicexemp °F gR TOWN OF YARMOUTH • r ':,, BUILDING DEPARTMENT Tr' Ma�.��aY.10, s �' 1146 Route 28, South Yarmouth,MA 02664 : GCd 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 l l� t \© , Oc, Work Addrs Is to be disposed of at the following location: Yamokil`l U t 4 4 W'c Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 4igS(AO Sig ature of Application ' ate Permit No. .� -- TOWN OF YARMOUTH 4 AN e • `'':_t. , ,c HEALTH DEPARTMENT ' `� ,� == � HEALTH DEPT. PERMIT APPLICATION SIGN OFF TRANSMITTAL S To he completed by Applicant: Building Site Location: -----7L : I v 'Po eNa r �© Ya\TM.o t_i4 Proposed Improvement: t V` A-t. ce,..-.,.. 0 C,3 c yv- C fr Applicant: 7 (��n^. S'ICv.ti Tel. No.: —41s1. Sa -1,0 Address: -f L! ' %o I\v De . ›ea4"t•'•it..1 MLiate Filed: L( I "-)C, tc) , **If you would like e-mail notification of sign off,please provide e-mail address: W Q'a® C Q c.r.,S�.-1&k Owner Name: � r` s .,-- Owner Address: l U c� �� 1 t'` YU 1\� r Owner Tel. No. $1 1SD clorq et 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, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed) - Note: Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. f?Th'171) REVIEWED BY: / DATE: �— 1 i"-a . 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'c'°. • ? ..!8.6 ?,,,,, • ogi 'i,4.•ell 46.4.9 ... :ii, -liff" il ,7 . 99.6 _..... p..:,., .-,.... 1 fk o- TOWN OF YARMOUT , _ ECEIVED• i H1 l 1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-1-45" APR 2 9 202Z -=,, ""rnel .' rd:' Telephone(508) 398-2231,Ext. 1250—Fax(508) 760-4830 ��CItlSi. �G.i BUILDING DEPARTMENT By __ — Engineering and Surveying Division Building Permit Review Residential and /or Commercial Buildings Name of Applicant: ` 1 \,,,..-. 0 61- Telephone or Email Address: ‘b5 '‘, 'ZC.c, Lu—('.- , n�C Proposed Building Location: t~. 1 i 4) . k Date Submitted: -1 - - D G - Requirements for review: Please submit one(1) copy of plans, to include: 1. For Residential: Site Plan showing proposed and/or existing buildings, proposed contours with bench mark,water service location, and septic system location. For Commercial: Site Plan showing details required by the Zoning By-law and revisions required by Site Plan review, if any. Note: Site plans must be signed and stamped by a Licensed Professional Land Surveyor and Engineer or Sanitarian. 2. House or Building- Floor Plan(s) and Elevation Plan(s) 3. One(1) copy of application. Reviewed By: yVviisAtV64 Date: I 12.1(2...2_ PLEASE NOTE Comments/Conditions: OA\1\ erti,.) 1) OR 0 .� i�4 Printed on Recycled Paper F Yx 96.4 As 4446, 444) { ,, �, "'-4 i N / N".".‹..5N \ NIM �0 i; t. I .. / 'S"'D =, 4,11 11' i V "I]' • 41411114‘ !y�; t e ij 4 4 i iQ 3° f ,1�i „„ .!- t - lift SEPOIC c'g* `�t a r v ♦ 99.6 7 Sears, Tim From: Sears, Tim Sent: Wednesday, May 4, 2022 9:02 AM To: 'ff302@comcast.net' Cc: Water Department Subject: 7 Lily Pond Dr John, I have reviewed your application for the addition and there are some items needed. Jl. Health Department sign off(under review) 2. Water Department sign off 3. Certified plot plan stamped by a land surveyor showing setbacks to proposed addition 4. 2 copies of plans in min.%" scale size 5. If the room is to be conditioned, then insulation values need to be shown on plan. If not, then it is required that there is a thermal break from the proposed room to the existing dwelling 6. There are pictures of footings included in this application. To make you aware we do not accept pictures in place of any inspection, and it is a violation of 780CMR Section R105.1 to begin work before obtaining a building permit. Please submit items 1-5 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. 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