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HomeMy WebLinkAboutBLDR-23-12909 ONE & TWO FAMILY ONLY- BUILDING PERMIT 1 Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State BuildingCode ` `` .' ■ ' ,780 CMR ii Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Q- Z � ---�,..___..__3.=' at';,ate Applied: i Building Official �� _— �-t(Print Name) afore Date SECTION I:SITE INFORMATION .1111 _1.1 Property Address: 1 N .�„�� ve n,. e, RI 1.2 Assessors Map&Parcel Numbers I V ED 1.1a 1s this an accepted street?yes / no Map Numberc. Parcel Number 1111 • 1.3 Zoning Information: 2023 ? O L7 /d/Lr 1.4 Property Dimensions: Z - District U: _6 (� gProposed Use Lot (sqAreatt f . 'BUILDING DE,�gRT} Frontage O `y— MENT 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided IIMIIIMIMIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIII Required Provided 1.6 Water Supply: (tvl.Ci.L c.40, 54 ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: Outside Flood Zone? Check if yesf3' Municipal 0 On site disposal system [ '' SECTION 2: PROPERTY OWNERSHIP` 2.1 Owner' f Reeor : Name(Print) C- f IC-��(,�t1C�; fry,State ZIP (, 1 No.and Street S�i`� :1' iL'S Ail t ri r1 L.�v`CIA l CMd'.v1 Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply) New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) 4 g, Alteration(s) Q dition 0 Demolition 0 Accessary Blds'`: 0 Nurrtbt r of Units ! Other ❑ Specify: Brief Description of Proposed Work ,, �' .4'40 s hid men !- SECTION 4:ESTIMATED CONSTRUCTION COSTS.\ Estimated Costs: . (Labor and Materials) Official Use Only 1.Building 0 Building$ C� C� I. g Permit Fee: '1,Electrical $ 600 C� 0 Standard City/Town A p Indicate how fee is determined: , Application Fee rinined: 0 Total Project Cost3(Item 6)x multiplier___, 2. Other Fees: $ � Y List: . "_"",-- ---' Total All Fees:$ st: $ S 9 CI L, Check No. Check El Paid in Amount:______Cash Amount: ❑Outstanding Balance Due: J. anh1nhim cop CAS1- - n -t" SECTION 5: CONSTRUCTION SERVICES Construction Supervisor License(CSL) License Number Expiration Date , Name of CSL Holder List CSL Type(see below) Na,and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 18c2 Family Dwelling Ivl Masonry • RC I Roofing Covering WS Window and Sidin• SF Solid Fuel Burning Appliances I Insulation Tele one Email address D Demolition Registered Home Improvement Contractor(HIC) HTC Company Name or HIC Registrant Name HIC Registration Number Expiration Date No.and Street Email address City/Town,State,ZTP 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 ❑ • SEC 1'.tON 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: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of pedury that all of contained in this application is true and accurate to the best of my knowledge and understanding. information ��LlSrx.) 1.*ct., 1.1 (1tvn, 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 riot 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.nov/oca Information on the Construction Supervisor License can be found at www.mass.2ov/dps 2. When substantial work is planned,provide the information below: Total tlaor area(sq.#I) Grossota living area .).} (including garage,finished basement/attics,decks or porch) Number of fireplaces Habitable room count Number of bathrooms Number of bedrooms Type of heating system Number ofhalf/baths Type of cooling system Number of decks/porches Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts ut L�y� =Yl Department of industrial Accidents i• .l'�' ' 1 Congress Street,Suite 100 Boston,MA 02114-2017 �.: _ 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): AL(C,,J r Rc,&K) 6�{/'YLY J j4(rt L-1-1Jt( Address: 1 a i-'t,c k.ct,\.6 ti.„" -Is • - City/State/Zip:. U fi.- ilt e t opt, 4 Phone #: —Clc` t,— . _5=j�Z s' Are you an employer?Ciiecic the appropriate box: 1.0 I am a employer with employees(full and/or part-time).* Type of project(required): 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. Newlin construction any capacity.[No workers'comp,insurance required.] 8- ❑RemodJeeling 3. I am 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. 1 will I0 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. i 1. Electrical repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet I ©Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6-0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other am' ,> 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 aft 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: 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. I52,§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 der the pain an e alties of perjury that the it forntation provided above7ue and correct, I Signature: / r Date: rf r 4- ' ` Phone m: a C � 7(S' Official use only. Do not write in this area,to be completed by city or talon official. City or Town: PermitfLicense 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#• _, ' _ BUILDING DEPARTMENT %e "4»; ,„ °i 1146 Route 28, South Yarmouth,MA 02664 508-398-2231. ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA'Ib: gph 1., .202- JOB LOCATION: f l2&`N f Qt ,,..) Lth•th i vi h v-1 /Z filet-kiifiem Ccl „{mrru er—v NAME STREET ADDRESS SECTIO-N OF TOWN "HOMEOWNER" o13!K.)(::a17ii, k c, a'-Lc-s-._'1 Itis. NAME HOW ' PHONE . WORK;PHONE PRESENT MAILNG ADDRESS tl tier a.) taN. 4 - GJa.' vt -ltP�- 14' cy C-4-C, t 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 R5.1.3.1) 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 I she shall be responsible for alj such work performed under the buildinn 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 requirements and that he,/ she will comply with said procedures and requirements. ---?/' er-k,--- ,,,,4611/4.---- 4 HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING OFNCIAL i.I INSURANCE COVERAGE: I have a current liability surance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes a $ 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 Cha ter 142 of the M . General Laws and that my signature on this permit application waives this requirement. X Check one: Signature of Owner or Owner's Agent 5wne.r) Agent h:horneownrlicexemp §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 (1 r cc 4k e%%'1' QA a"rn',cvi_` Cpo ff Work Address Is to be disposed of oat the following location: I�-�,y, � 144,0 ( Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Signature of Application Date Permit No. ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: /, /-4 ,,c l<a h Owl RJ Scope of Proposed Work: ui - , 1,1 . c c- 4 L. t �m.r� i�ti c-c� C r�;f iely� � Lcf) 1Y-01vt Cl60 1C. i rt (9r P4.1pifizzc.�1y brn fr t. (1 r,tLS . CY)(S C' {i re�n.s!'�: "+ big v---y..4e ) Date: 1 / 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.—508-398-2231 ext. 1241 Conservation—508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept.—508-398-2231 ext. 1250 Fire Dept. —Kevin Huck/Scott Smith, 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 of these regulatory authorities has their own requirements outside the jurisdiction of the 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 Ackr dement: r 9/7 ..)—A-3 Applicant's Signature Date Rev.Jan. 2019 kf\ 6 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 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 a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: , (, a- Z.3 - / 5'47ate Applied: \'r,. ��` � /' Building Official(Print Name) i ature Date r SECTION 1:SITE INFORMATION 1.1 Property Address: IL/ Nc'c K�.nu,— R 1.2 Assessors Map&Parcel Numbers R '�_c z I� V E [� i Cs-'- CYO Wit:-kec r�- f.2 - 3 ' 1.1a Is this an accepted street?yes / no Map Number Parcel Number $FP 1.3 Zoning Information: i 1�23 1.4 Property Dimensions: � ¢�l�L,irt� Ohl !l1/U D.'IG -e Ef�gRT Zo ingDistrict Proposed Use Lot Area(sq ft) Frontage(ft)I uy ILDINGD MENT 1.5 Building Setbacks(ft) - Front Yard Side Yards Rear Yard Required Provided Required Provided Required i Provided 1.6 Water Supply: ((vi.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal sal System: Zone: Outside Flood Zone? p Y Public Private 0 — Municipal 0 On site disposal system Ci/ Er pP Y Check if yes SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner' f Record: ,4IIA)t t;6;n) U--4,441dt-lin. Itanoat"-portW'i O- C.1 26, .7SName(Print) ty,State,ZIP /:. !+ci-k.1-tICVA R4 'Y.' 1(trt�(t i 1 tivtt"c r vtd— No.and Street ��y � ' f f'� �cC1 Y Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)_ New Construction© I Existing Building Cl Owner-Occupied ❑ Repairs(s) Er Alteration(s) 0 (Addition Cl Demolition 0 I Accessory Bldg. 0 Number of Units j Other 0 Specify: Brief Description of Proposed Work'`: , — A }},, {� (> r11'.tl/r'i( i•' J\F��C.Ln valC;tMl .('�/1`�� .i Lti'lY�- {��(',(,„ 4,,,c(.... ._.._ 1 rit>L fat4 ii.h(`+- '1 fl is f 'cre-yYl --t- ki)c)y",, i... pv.'AL,_t."x s i - 5 1tiL,t' [N,' t.4,t.,,A. ;,� -fs. .6.$) VV.'E:.d C-) f f r' �¢1��'tu piA i Shh ba 1-e ine I- . SECTION 4:ESTIMATED CONSTRUCTION COSTS, Item Estimated Costs: _ (Labor and Materials) Official Use Only 1.Building $ j. Q ODBuilding Permit Fee:Silk,' Ct I. � ___Indicate how fee is determined: El Standard City/Town Application Fee 2.Electrical $ L L 3.Plumbing $ 0 Total Project Cost3(Item 6)x multiplier x 2. Other Fees: $ 4.Mechanical (HVAC) $ List; , 6— 5.Mechanical (Fire Suppression) $ Total All Fees:$ . 6.Total Project Cost: $ y 0Check No, Check Amount Cash Amount: ❑Paid in Full D Outstanding Balance Dlae: 9601h1nPin9) c mCaS - Ile