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Home My WebLink AboutBLDR-23-13047 i ! —7 ONE &TWO FAMILY ONLY-BUILDING PERMIT Town of Yarmouth Building Department �of r� 1146 Route 28,South Yarmouth,MA 02664-4492 - 508-398-7?31 ext. 1261 Fax 508-398-0836 + Massachusetts State Building Code,780 CMR .4.,-:. Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Tito-Family Dwelling This Section 'or Official Use Only Building Permit Number: A7Date Applied: /7_, - , Bull ' O at riot Name) �_ _...,. -----Signature G�1l7 Signature Date CTION 1:SITE INFORMATION 1.1 P p Address: r 1.2 Assessors Map&Parcel Numbers to Litt e 1)1fper LAND. Zia 1.i a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: 3 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 1 ,, Provided 1 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Publics Private 0 Zone: _ Outside Flood one? Municipal 0 On site disposal system g Check ifyei ' SECTION 2: PROPERTY OWNERSHIP' •ner'of e�c Nactfe Prim 0tk(' 'TIV it) lit! , V1A 0�,60-1- ( ) J State,ZIP lb Li4He VIQ li L t x 41.3-a3�- 6`I I� _1 rc Ns�§t inl : No.and Street Telephone Email Address Ce.lisl SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building$. Owner-Occupied El Repairs(s)7t 1 Alteration(s) 0 , Addition 0 Demolition 0 Accessory Bldg.0 Number of Units 1 ! Specify:Other 0 S fY: - Brief Description of Proposed Work: (1,0 t... 7')(6r q-Min iftcst M l l f i,tom -- SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ 4,00T) ,OGTa 1. Building Permit Fee:S Indicate how fee is determined: 2.Electrical $ 6 c0 D ` 0 Standard City/Town Application Fee I ��" $ ❑Total Project Costa(Itew multiplier x , J 3.Plumbing Lk�0 0 2. Other Fees: $ 3 3 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ j 6.Total Project Cost: $ I6 '660_ Cheri:No. i Check Amount Cash Amount: /� ❑Paid in Full 0 Outstanding t� t- D r DEC 012023 5 .47 B L -i ARTMENT By: 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 i Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State ZIP , R Restricted 1&2 Family Dwelling 41 Masonry RC I Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I insulation Telephone Email address l D I Demolition 5.2 Registered Home Improvement Contractor(HIC) I•fIC Company Name or HIC Registrant Name INC Registration Number Expiration Date Na.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 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 VN "1 \tmr"� to act on my behalf,in all matters relative to work authorized by this buiidingit application. 4� Gi Grrib 11 (3t) Print Owner's Name(Elect>2biic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering name below,I hereby attest under the pains and penalties of perjury that all of the information con i this application is true d accurate to the best of my knowledge and understanding. Xrint Owner's or Autho. ed Arent' ame(Dec nic Signature) IDat� NOTE& 1. An Owner who obtains a building e 't to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improv ent 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.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 a Number of half/baths 0 Type of heating system t 1tr Number of decks/porches Type of cooling system Pt- - inclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" /% ' ".. '- • The Commonwealth of Massachusetts ., I.min I Department oflndustrialAccideiats _ f- 1 Congress Street, Suite 100 e" Boston, MA 02114-2017 5,y1t www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly • Name (Business/Organization/Individual). Vil+ 81 C Address: I b `,.({- -to ')i Rev LRtve.. �1 Iiiirmt„t, , b �4, Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. [New construction 2.111 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3. I am a homeowner doing all work myself 9. _ Demolition y [No workers'comp.insurance required.]t 4.E I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will in 10 Building addition ensure that all contractors either have workers'compensation insurance or ar sol p 11.El Electrical repairs or additions proprietors with no employees. - 12.E Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.$ 13•El 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. 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. if: 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 certi under the pains land penalties of perjury that the information provided above is true and correct. .d,..6? SignatureK `,, G �(( � '��, Date: t(1•� Phone#: 13 - , -�`� 19 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: o1'Y ,,. TOWN OF YARMOUTH 4� 4`- Q 1 n� 14 BUILDING DEPARTMENT �� .s :r 1146 Route 28,South Yarmouth,MA 02664 S08-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DAl'E: JOB LOCATION: tto Lt- r \e 1/t4 1.,1 .N-. Im t`�t�,ti►' cA Ls ,9. AN _ P S��T AD RESS SECTION OF TOWN "HOMEOWNER" Vt de a 111 f_Oc LA 46`6y f\ NAME HOME PHONE , WORK PHONE PRIENT MAIL TG ADDRESS 0 1 k • 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.I.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.I.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 requi ments and that he / she will comply with said procedures and requirements. ( HOMEOWNER"S SIGNATURE)"7 al., C /( r // APPROVAL OF BUILDING OFFICIAL 1 II INSURANCE COVERAGE: J 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 §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. 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 (b_ Lc#k1tppeir lft !� 04N O9 4 Wok Address Iry Kvs-fic ‘i 611,61a Is to be disposed of oat the following location: 3.9i Berl v DAm I ' 1 ik'1oW4A Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 1‘ 1.3t.))0,3 i nature of App ica ion Date Permit No. --B v kONA c:i 6 'PI ,a I I L ++(Q i tpp r Lu e_ i6i \$ v'' \f) 6U69 I ..,6 i ___________________ ___,. .___. fit, c ry "3&'' C -,,b " Slf,aw,, , 0 4----,‘ >k a ti- f •-1 a. L"I p I 0i Wi z W' o 0 2 1 N A TV (