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HomeMy WebLinkAboutBSHD-23-52 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 {' 64' )-.1 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code, 780 CMR a Building Permit Application To Construct, Repair, Renovate Or Demolish \ a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: _i%5-/0- 7 3-52— Date Applied: Building Official(Print Name) Signatu Date SECTION 1:SITE INFORMATION 1.1 roperty Address: 1.2 Assessors Map&Parcel Numbers 5:5 Irl1n5lpw G/ ,, Rid,- W y 32 46 1.1 a Is this an accepted streets / no _ Map Number Parcel Number 1.3 Zoning Information: r 1.4 Propsrrty Dimensions: Zoning District Proposed L Lot Area (sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 30 4c I zn 2 0 110 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 6� Private❑ Zone: — Outside Flood Zone? Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Builders LL C. c$ouk 4- o fillatOint) �ur• Ou l�( ity,State,ZIP y 10.$ox t Dt (cee) 685-755g ph losbv/kcus di corneas 6,he& No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ ) Existing Building hi' Owner-Occupied 0 1 Repairs(s) 0 l Alteration(s) 0 l Addition 0 Demolition 0 I Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'`: 6 VIVI( " SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: h (Labor and Materials) Official Use Only 1. Building by/t [ ) $ 6ow . 1. Building Permit Fee:$_)________,Indicate how fee is determined: 2.Electrical $ ....----- ❑ Standard City/Town Application Fee �� ❑Total Project Cost3(Item Q x multiplier x $ 2. Other Fees: $ rj ra.gc"4. c ) icy D i...---- List: 5.M hanical (Fire Stpp esskti6 n 1 2023 $ 1 ........---- Total All Fees:$ 6 ••D .001 Check No. Check Amount: Cash Amount: idUILDIN 007. 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ! �h CS 0 2 U is 20 Name of CSL Holder a S License Number Expiration Date 4 ,a. 0X !D y List CSL Type(see below)Dr ry e.d No,and Street Type Description /W71 s , /�_.__D_ b U Unrestricted(Buildin:s up to 35,000 Cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofintr Coverin: ® Window and Sidin �(�05.7,5-,�5- � ,��`c SF Solid Fuel Burning Appliances c D Insulation ele.hone Email address� „e 5.2 Registered Home Improvement Contractor(HIC) Demolition pkoj C Co any i ame or HIC Registrant Name HIC Registration Number Expiration Date No,and S reet ity/Town, State,ZIP All S—?5SE Email address 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 I 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 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. i/c1 �c [ / r Print 0 s or Authorized Agents Name(Electronic Signature) ' '2`3 Date NOTES:1• An Owner who obtains a building permit to do hi b s/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 Qov/oca Information on the Construction Supervisor License can be found at www.mass..c.rov/d 2• When substantial work is planned,provide the information below: w/� Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Number of fireplaces Habitable room count Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Type of cooling system Number of decks/porches Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" , i '— �.. .i ne commonwealth of!Massachusetts Department of Industrial Accidents _..�; �; Boston 1 Congress Street, Suite 100 ="a_,�= �,.` , MA 02114-2017 Mr'. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Name (Business/Organization/Individual); Please Print LeQibl U% Address: o • City/State/Zip: So. GZrm©cP64.. Phone #: ' p (SS 7.57S3— Are you an employer?Check the appropriate box: LC]I am a employer with employees(full and/or part-time).* Type of project(required): 7. 2.0[am a sole proprietor or partnership and have no employees working for me in ❑New construction any capacity.[No workers'comp, insurance required.] 8. El Remodeling 3.0 I am a homeowner doing all work myself: [No workers'comp. insurance required.]t 9. [I] Demolition 'I.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 Building 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. These sub-contractors have employees and have workers'comp. insurance.: 12. Plumbing repairs or additions 6.I We are a corporation and its officers have exercised their right of exemption per iMfGL c. 13. ROOF repairs 152,§I(4),and we have no employees. [No workers'comp. insurance required.] 14.Li Other i F *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy in . anon. t Homeowners who submit this affidavit indicating they are doing al!work and then hire outside contractors must submit a new indicatingaffidavit 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, such.rt I am an employer that is providing workers'compensation insurance for my employees. Below is the policy a information. Insurance Company Name: p y and job site Policy#or Self-ins. Lic.#: Expiration Date; Job Site Address: t Attach a copy of the workers' compensation policy declaration page(showing thepo icy number an Failure to secure coverage as required under MGL c. 152 d expiration date). 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 day against the violator. A copy coverage verification, of this statement may be forwarded to the Office of Investigations of the DIA for insurance a 1 do hereby certify under the pains and penalties of perjury that the information provided above S!anature: d is true and correct. Phone#; Q _ SS Date: J/// 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.O Other Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 6. p or 5. Plumbing Inspector Contact Person: Phone#: TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" NAME HOME PHONE WORK PHONE PRESENT MAILNG ADDRESS 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 assessor_v 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 res onsible 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 requirements and that he / she will comply with said procedures requirements. p ures and HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING OFFICIAL NSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements Ch.142. Yes No q meets of MGL 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 NSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage re Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this Check Signature of Owner or Owner's Agent Owner one. 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. 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 5 mov , Work Address Is to be disposed of at the following location: T (I) � Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Applicant Date Permit No. ONE or TWO FAMILY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: j 8 WInc/o[ 6-ray ,RA, y/� ) t• i i1 Scope of Proposed Work: ,� , J car 4forajte_ -ox/mc , /ox2f‘. Date; !,�//,2� 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/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 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. Rec ipt Acknowledge . Applicant's Signa /2,/ Date Rev. March 2022 cs Y '' 4/7-4'-:7 a�d 4 I / 1‘,.. 8.,?) ' s k /., la V 1�x 4bpi ` �R ��k IlQv it�l $ I s C�arche_ `ca_le. 1°`r-- 3Q' 1 LRS 13 vILDERs LLC Pt. Box 1 o,P r n_ Yeirrnn r,i-, MA -- PaLincim_ fourvdect.-ibr-, det bot uare. washex aziL aroveici 9 en " perimc6c r " 5-8 Wirl.sloc.c) Gray , ,0(-) NOV Itej e,)(1.561;-.19 friai I S? rjc . dara c„, -pi)tipsI I der,sLL C,, -P. 2.)0,.4 109 . f4 10 1