HomeMy WebLinkAboutBLDR-23-13032 - applicationONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department
1146 Route 28, South Yarmourh, MA 02664-4492
508-398-2231 ext. l26t Fa\ 508-398-0836
Massachusetts State BLrilding Code,780 CMR
Bttilding Pernit Application To Consb.uct, Repai., Renovate Or Dentolish
a One- or Two-Fanily Dtt,elling
Building Pelmit Number
This Section For Official Use Ooly
Date Applied
SDCTION l: SITE I\TOR\{ATIO),1
1.5 Building Setback (ft)
?O Front Yard Sidc Yards Rear Yard
Piovided Required Providcd Required Providcd
jo ZO "ts lt z 'ZD
1.6 lvater Supply: (tvt.C.L c +0, fSg
Public tr Privare E
1.7 Flood Zone Infoimiion,Zone Outsrde FlJod Znner
Check ify€str
1.8 Sewage Disposal System:
Nlunicipal tr On site disposal sysrem El
Alteration(s) tr Addition tr
Demolition tr | Accessory Bldg. tr.Number of Units
Building Official (Prinr Name)Signatu.e
:tu Rl ,^'tL<
1.2 lssyors NIap & Parcel Numb
accepted street? yes ir'Iap Number ParcelNumber
Date
l.l Property Address
l.1a Is this a
1.3 zo ning Information:K 4o a
Zoning District Proposed Use
Ownerr of R rd:
1.4 ProperR Dimensions;tA2ogt)
ersq
k,
SECTION 2: PROPERTY OWNERSHIP'
Lot Arca (sq ft)Frontage (ft)
OZ 1Name (Print)
No. ond S
CiB, State,P
0 ZY)
Teiephone
SECTION 3: DESCRIPTION OF PROPOSED WORK1 (check all that a pplv)
Existing Building!9 O$Ter-Occupied tr
Other tr Speci$
Brief Description of Proposed Work2 , D,,.r_,/R.5 - 6"ra.4Sla.. drtJ,
n0
SECTION J: ISTtNlAT[,D CO]{STRUCTION COSTS
Estimated Costs:
Labor and Materialslrem
1. Buildirg sgSoa>.oo
2. Electrical S
3. Plumbing s
4. Mecharical (fryAc)s
5. Mechanical (Fire
Suppressior)S
S
l. Building Permit Fee: S_ Ildicate how fee is detenniled
O Standard City/Tor,m Application Fee
tr Total Project Costr (Item 6) x multiplier _ x _--
Check Amount: _Cash Amount:
E Outsta:rding Balance Due
2. Other Fees: $
List;
tr Paid in Full
Total A.ll Faes: S
Check No.
Official Use Only
no
CusL zo@ S,"A: /.o^
Email Addi6s
Required
New Construction D
7o
Repairs(s)
6 Total Project Cost:
SECTION 5: CONSTRUCTIOl,i SERI,ICES
Type Description
U
R Reslricted l&2 Famil Dwellin\I lvI
RC Roofing Coverin
Window aad Sidin
SF Solid Fuel Buming Appliances
I
5.1 ConstructioD Supervisor Licetrse (CSL)
t-lnrtenl € Elala_
Tel
\Iv,S
address
TZADLEY A"r'--
"-/A dtj62--
'79 -qr$3n1 p ao
Namc ofCSL Holder
Ciry/Towo, State, ZI?
5V 13
No. and Strcct
fu?x.sort
D Demolition
5.2 Registered Home Improyement Contractor (HIC)
"44nrkh.J LEDI--t itoq31
on Date
16,-3o11D1o'2--A
<:t
,TP
B/?4{L €Y
Tele/Town Sta
1 ZI
HIC Company Name or HIC Registrant Name
No. and Street
HIC Registration Number
€_telL-c aw1
mail address
SECTION 6: IVORKERS' COIIPENS.ATION I\ISURANCE AFFIDAi,IT 0!t.c.L. c. 152. S 25C(6))
Ca?A - lobo.lL ,/a
Liccnsc Number
Lis! CSL T}?e (see below)
Expiratip-
j Workers Compensation Insurance affidavit must be c
Unrestricted to 35 000 cu. ft.)
ompleted and submined with this application Failure to providethis affidavir will resulr in the deDial ofthe lssuance oftbe building permit
Sigoed Affidavit Anached? Yes WNo
SECTIO)i 7a: OFNIR AUTHORIZ.{TIOIi TO BE CONIPLETED WI{ENO}\NER'S AGENT OR CONTR{CTOR APPLIES FOR BIIII-DII(G PERr\IT
l, as Orvner ofthe subject properry, hereby au..horize l/h-t 4,- E P;. tt
to act on my behalf, in all maners relative to lvork authorized by this building permit application.Lr'
Print Olener's Name (Elcfironic Signature)r? - Zz-Z 3
Dat.-
By entering my name belolv, I hereby attest under the paiDs and penalties ofperjtul that all ofthe informatiou
cootained in this application is true a::d accurate to the besr ofmy loorvledge a,.d understandi:rg.
Print Owrer's or Authorizid Agent's Name (Elcctronic Signaturc)Dar".
l. AnO*aer rvho obtains a building permit to do his&er own rvork. or an owner rvho htes a! uffegistered cotrtractor(not resistered in the Home Improvement Contactor (HIC) Program), will 491 have access ro the arbitrationprogam or guaranty firnd under M.G.L. c. 142A. Other impoftant i[formation otr the I-llC Prosram can be foulld at*rryw.mass. gory'oca hformatiol on the Coostruction Supervisor License can be founri ar wwrv.mass.gov/dps
ECS otTN b \11-Eo R Ro LTT oII ZEI{I D GENT ED LC TIAR,1.\o
NOTES:
2. When substaotial rvork is planaed, provide the information belorv
Number of lueplaces
(uicluding garage. finished basemenVattics. decks or porch)
Number ofbatbrooms
Open
Total floor area (sq. ft.)
Gross living area (sq. ft Habitable room count
Nrulber of bedrooms
Number ofhali/baths
T)?e ofheating system
Type of cooling system
Nu:rber of decks/ porches
Enclosed
"Total Project Square Footage" may be substituted for..Total projecr Cost''
aoL<
Insulation
TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-223 I ext. 126l Fax 508-398-0836
Office of the Building Commissioner
BUILOING DEPARTMENT
DEMOLITION DEBRIS DISP OSAL 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
cond ucted at €'l
Work Address
ls to be disposed of at the following location:vt|y't\
Said disposal site shall be a licensed solid waste facility as defined by M.G.L
Chapter 111, Section 150A.
iz-zt'zz
Signature of Applicant
/-L
Permit No.
Date
Address of Proposed Work:
Scope of Proposed Work:
517 ,^1"., y',+<*r-nt fZeJ il.lfi,cunnr
I
Based on the scope of work described above, the applicant is required to obtain approval sign-
offs from the following departments as checked-of below:
_Health Dept. -508-398-2237 ext. 7247
_Conservation - 508-398-2231 ext. 1288
_Water Dept. - 99 Buck lsland Road,508-771-792!
_Old Kings HWY. Hist. Comm. - 508-398-22637 ext.7292
_Engineering Dept. - 508-398-2231 ext. 1250
_Fire Dept. - Kevin Huck/Matt Bearse, 96 Old Main Street, SY
Note: Please call Fire Department for an appointment. 508-398-2212
Other
Appropriate plans and/or application shall be provided to each departments checked-off above
Each ofthese regulatory authorities has their own requirements outside the jurisdiction ofthe
Building Department. All applicable approvals shall be obtained prior to submitting a building
permit application to the Building Dept.
Thank you for your cooperation.
Receipt Acknowledgement:/Z tl
Applica nt's Signature
Rev. March 2022
te
Z
ONE or TWO FAMILY - BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Date: lZ- R'Za
I Commonwealth of Uassachusetts
Dlvislon of Occupah<r.tal Lrccnsure
Board ot Eutlding Reqqlattons aod Standa.ds,lonstrt cr:cq;&i$Jl-{,iS.-. r : =r.. ..
=' 'i
csFA-r06042
rATT}IEIV REr'-
5! BRADLET,,AVE
EROCrron !A ?z:tr'"
)-ojt,..,1 l\l \-
!'
res:04/08/2025
it-ni,.?rJ
Undersecr ltary
elj
Commissioner j t7-t- t. !1,,-,.-
THE CO*I
'O'{!YEALTh
OF & ASSACTTUSET?S
Offioe of co lsurn r Affairs & Busin€ss Bagrrlalblr
HOI'E IHPROVEIiIENI C f,}TTBACTOR
TYPE: I.|diviit alB)oisltattoo Efrratbn156459 t3t'-18125
'.1!.I'iirE)i1 !: t -
I\,{ATTHEW RIEDL
58 BBADLEY AVE
BROCKTON. MA ( 2302
\\-orkers' Compensatio
Th e Co mmo n w ea lth oif Il[ ass ac h us etts
D ep a rtme nt of I n d ustr ial A c c i de n ts
1 Congress Street, Sttite 100
Boston, MA 02 I t4-2017
www. mass.gov/dia
n Insurance Affidavit: Builders/Contractors/E Iectricians,rylumbers.TO BE FILED WITH TUE pERTIIITTINc _{tfTHOR ITY,AD Iicant Informat ron Pi e Pr LeeiblName (Business/Organizario lndil,iduai):?tas'
Address tko
City/State/Zip B o O2ghone #'-79 ) -306-31 11
'Any applicanr thar chccks box #l mt Homeowners who submit this affidavi! inCica:i ng thcy arc doing al! work and thcn hirc outs
ou! the scclon below showlng lhcir workers'
idc contractors musr submit a new afiidavit indicati
compensation policy infonnaoon
ng such.1Coniractors Lrat check !\is box musi alrached an adCilonal sheet showing the name ofrhe sub-contiactors and state.l,\,hethcr or not those.ntitiesemployces_ li the sub,conniciors havc loyecs, rhcy &us! provide their workcrs,
I.! I an a employer with _-cmployees (firll and/or pa(-tine) ,
2 p I am a sole propriclor or parbcrship and havc no cmployees workrnq for mc rn' any capaclty. lNo workers'comp tnsuraxcc requlled.]
I am a homeowncr doing all work mysclf [No workers.comp. insuranca required.]i
I am a homcorrncr and will bc hirint contracors ro conduct all work on my proDeny I wtllensurc urar alt conEaclors eithcr have workars, compcnsation insr.rrancc or-uc solc
.
proprietors wih no cmoloyccs.
I ain a gcneral contractor and I have hircd thc sub-con.\ractors lisicd on the anached sheet.Thes. sub'contractors have cmploycas and havc workers,comp. insunncc.t
Wc are a corporarion and rts officcrs have excrcised rherr nghr ofexc:.nDoon rcr MGL cl5l, S l(4), and we hav. no employees 1xo *orkc.s, .o,p-lnsu.a"". i"+.ljl ""- '
Arc you :rn employcrl Cherk the ippropriatc bor Type of project (required)
Z. [-I New construction
emodeling
emolition
l0 ! Building addition
I I.E Electricai repairs or additioos
8
9
t2
t3
r4E
D
Plumbing repairs or additions
Roofrepairs
Other
I am an employer that is providing workers,
irJormatio n.
lnsurance Company Name
comp. policy number
compensadon i surancefor m1 enplolees. Belota) is the policy andjob site
Policy # or Self-ins. Lic. #
Job Site Address:.....' -.-..----.ttt,.h ".opy or lr',lt;Tily",,*-tt*rr","" *r",railure to secure coverage as requite .under MGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00and'/or one-year imprisonment' as rvell as civil penalties in in. ro* J" srop woRKbRDER.j" r,* ot up ,o $250.00 a
|o"|.};:,j|'"i["u"],",j1or'
A copv of this statement mav b. f";;;; ;; the office or rr,.rtig^tio"r'"r1h.'itA ro, inru,"n".
Expiration Date
I do hereby certily uni,er the pains and penalties perjury that the inlornution provi,ded above is true a d corrcct.
re Date /?
P | -3a8
o not write ih this area, to be completed by ciO ot tovn ofJiciaL
lssuing Authority (circle one):l. Board of Health 2, Buitding Departmert 3. City/Town Clerk6. Other J. Electrical Inspector 5. plumbing Inspector
Phone #:
OICcial use ont!. D
City or Town:
Contact Person:
DAIE (IOO/YYYY)
03/158024
THB EEBTIFICATE IS ISSUED AS A TiATTER OF I}{FOFMAT]ON ONLY AND CONFERS NO BIGHTS UPON THE CERTIFICATE HOLDER. THE
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OB ALTEB THE COVEHAGE AFFORDED BY THE POUCIES
BELOW. T}IIS CEBTIFICATE OF INSURANCE DOES NOT CONSIITUTE A CONTBACT BETU'EEN THE ISSI.qNG INSUBEBTS), AUTHOFIZED
REPRESENTATIVE OR PRODUCEH, AND THE CERNFICATE HOLDER,
IttPOfr fff: ff*Dsr i:sb lrs&16 sa $DDIrlO lALilr{SUSEO, lhe polqdis6)T,rusi.teadorBed ,,SUBAOGATJO EI^,AIVED, sr@ b
ttro ltlllrt nnd condtirars ot ttE FliG", cgtain policies r,riy requirc an €n6rs€.nea[ A sral€meot on rfiis c..liHc docs nd cordc. rigftts to the
c!.titical€ holde. in tieu ot such endois€meri(s).
Bridge lnsurance Assoc
80 Lengley Road
2nd Floot
NeMon Centre lrlA C2459
i?lllfr scott Barats
PHONE (617) $r17n f# &,,.{617) s6+1888
*lEpr-Nortolk&Ded€rn
INSURED
MA 02302
/-,^Co'fii)o CERTIFICATE OF LIABILITY INSURANCE
CEFTIFICATE 1r BEN:HEY{gO}t
AJ 003657
@ 19€&2014 ACOBD CORPOFAnON. All rights reservsd.
thaACOB) EaE€.aqC lqqo are la.n.nqed Eark-s ot ACOBD
THIS IS TO CERTIFY T}AT THE POTICIES OF INSURANCE LISTED AELOW HAVE AEEN ISSUEO TO THE INSUREO MMED AEOVE FOR THE POLICY PERIOD
INOICAIED, NOTWTTHSTANOING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONIRACT OR OTHER OOCUMENT WTH RESPECT TO Vlt]ICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, IHE INSURANCE AFFORDED BY IHE POLICIES DESCRIBEO HEREIN IS SUBJECT IO ALL THE TERMS,
EXCLUSIONSAND CONDITIoNS oF SUCH PoLlclES. LIMITS SHOrr\rl,IiIAY itAVE BEEN REDUCED BY PAIo CLAIMS.
uta,Is
x COMIIIERCIAI GEIIEBAL LIAALIIY 0214,,2022 \ o2i4na23 1.000,0c0
x 50.000
5,000
1,000,000
AGG E
PFIGJECT LOC
2,000 000
2,000,000
a
I$lOEElIf Ll4B{]rY co Br,,iE! sillciE !rtir:s
x
AlL OW.IED
AUTOS
HIRED AUTOS
BOOLY lN,lURY {Per peen)S 50 000
sc1]EDIJ'.EO
AUIOS
NONlWNED
EOOILY LNURY (Peraedant)S 100 000
50 000
s
uSBElt taa
E.XCESS UA8
woRxEas @FEt'tsa1toN
AND EIPLOYEFS' LIAEIUTY
ANY PROPRIETOR/PARTNER,€XEC!'TI!€
OFF]CERTT,EMBER EXCLUOTO'
DFsr^lrpr'.N.F.PFearnra sh
fl
ER 01N-
E L EACN ACC DENT s
EI D SEASE. Eq FMPLOYEE s
F NISFASF. POIICY IIM]T
I
i
OESCRIPTIOII OF OPEBAIIOI\F /IOCAIO S/ VEN0-ES (ACOAo rfi,lddldfirl E.rn.r& S.h.dulq m.y !. alt .h.d n mE.Fe i. Equir*,)
Attach a copy ofthe Gen€ral Liability Additional InsLr@d EndoBemefit(9 .eflecting the followang: BELL PAR|NERS INC.,IHBR SUASDiARIES,
LENDERS, AND THE OWNERSHIP ENTITY(S) OF THER OWNED OR MANAGED PROPERTIES have b€en included as additional insured on th€
general liabi,jty policy. INSURANCE AGEI,IIS: lfyour insurcd has a schedul€d endors€ment the aforementioned parti€s must b€ includ€d in the
schedule and a copy ofendorsement must be submitted along wrth the ceftiflcate. lf your insured has a blanket endorsement. rt must also be
submitted along wirh *l€ cedmcate. tanguage r€ading additional insuEd status do€s not ne€d to b€ Bflected in the D66ription of Op€.ations
s€ction of the certifcate.
SHOULO ANY OF THE ABOVE DESCRIBED POLICIESBE CANCELLED BEFOBE
THE EXPIRATION OATE THEBEOF, NOTICE \IIIILL BE OELIVEFED IN
accoRoaticE wlTH TtE Po{-rcl FRotlt}ol{s.TOWN OF YARMOUTH
AUIHONEED REPBESENTATIVE
ACORO 25 (2A14JO1 )
Matthew Riedl
Design Biedl
5€ Bradley Ave
Brockton
I i
I
x
I
II
I
lI
M-
CANCELOLD