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Home My WebLink AboutBLDR-24-7 e 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 ,A,` ; Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish .i. a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 13w2_ .)J) I Date Applied: j ‘,/,--2; , Ad/2" Building O cial(Print N Sr re Date SECTION 1 ITE ORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers iS W:i4F A/.c' tctne 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 5,�., Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) j'( Front Yard Side Yards Rear Yard ",�,/ Required Provided Required Provided Required Provided I , 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ar Private 0 Zone: _ Outside Flood Zone? ��- Check if yes❑ Municipal hd'On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 1MG-rA re-f elti.v'. y0.c(AA.iJcr+tti Name(Print) ' b�°� City,State,ZIP lg trtS.tcAstoue< («.L No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other EC Specify: F: Brief Description of Proposed Work': rcc.,w.e c ,el F;.A.l'94 I e`1C .4 Zoo Rr p/Atirvy t SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only RECEIVED 1. Building $ 1. Building Permit Fee:$ Indicate lac Le is determined:" — 2.Electrical $ 0 Standard City/Town Application Fee JAN 05 2024 3.Plumbing CI Total Project Costa(Item 6)x multiplier x $ 2. Other Fees: $ BUILDING DEPARTMENT 4.Mechanical (HVAC) $ List: _3 s d0 ay: _ 5.Mechanical (Fire • o231p/1 Suppression) $ Total All Fees:$ t/ 6.Total Project Cost: $ 3$t b '- Check No. Check Amount: Cash Amount: 0 Paid in Full ❑Outstanding Balance Due: r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) e°.� �� .55-e 65— t03b3t 45i'3afaod5 Name of CSL Holder License Number Expiration Date 14{ e`iik. . 510A,Ct nd List CSL Type(see below) 'J No.and Street 1` Type Description / C{'�QGr 5 �, R a,z�(y State,ZIP 11 U Unrestricted(Buildings up to 35,000 Cu. ft.) City/Town,nit . R Restricted 1&2 Family Dwelling M Masonry • RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Telephone I Insulation Email address D ' Demolition ' 5.2 Registered Home Improvement Contractor(HIC) ex A-co. �a.e_4 sS e. c v,e peA T 4�f 3 3a o�I-11C Company Name or HIC Registrant Name HIC Registration Number 41_____‘' ation Date rH ?.ne -TSta,i,ci R .. No. and Street aseic% GrAck55{'6)a eta,t.eaw+ at+cifeivet+, 1ilut o a 1 3 R 08,-)0 -77d`l6 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 Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. V 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 accurateto the best of my knowledge and understanding. 1L!/1 G1.2L/ .166 �J CL�� Print Owner's or Auth rized Agent's Name(Electronic Signature) — Date NOTES: I. 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.) Gross living area(sq.ft.) (including garage,finished basement/attics, decks or porch) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths 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" • o The Commonwealth of Massachusetts I � 17, Department oflndustrialAccidents 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): (1 ct�l ` c:c 4%5 St._ C<A p.Q„ti 4 r. Address: [!-f he t5t City/State/Zip: 1'41a�-Ee�o:sL�-t t44 t�a73ct Phone #: FJO' -7 U7 - 17 3 U Are you an employer?Check the appropriate box: Type of project(required): LE I am a employer with employees(full and/or part-time).* 7. w construction 2.dam a sole proprietor or partnership and have no employees working for me in capacity. 8. Remodeling any p ty.[No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole l 1.n Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.O 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.1 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other I':✓� w .4 152,§1(4),and we have no employees. [No workers'comp. insurance required.] 09€1,ti.Q.,4, *Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy �'X p 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. 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: Pi-te...f (zc (4•-1 5 . Policy#or Self-ins.Lic./: L 3 7 5o0 0 I t - 0 Expiration Date: Job Site Address: I S ireW trl I o e... 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 S1,500.00 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: � Date: 1 /5 l `0")``"a i Phone#: ! — 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 4: TOWN OF YARMOUTH o( . _ BUILDING DEPARTMENT 111-^_ ; •477.9 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA JOB LOCATION: NAME STREET ADDRESS SECTION OF TOWN "HON OWNER" NAME HOME PHONE WORK PHONE PRESE MAILNG ADDRESS CITY OR TOWN STA 1'h ZIP CODE The current e -mption for 'Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow su homeowners to engage an individual for hire who does not possess a license,provided that such homeowner shall :et as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeo er: Person(s)who owns a p. cel 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 att. hed or detached structure assessory to such use and/or farm structures. A person who constructs more than one ho ,e in a two-year period shall not be considered a homeowner; such"homeowner"shall submit to the building official, .n a form acceptable to the building official,that he/she shall be responsible for all such work perfoinied under the ►uilding permit. (Section 110 R5.1.3.1) The undersigned `homeowner' ass . es responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and r �.ulations. The undersigned 'homeowner' certifies t' t 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 APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial e• ivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked ves, please indicate the type coverage by chec .g the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not h:ve 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 t/ 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 t uN.:.:6 cif to;f tyc Ia ) \fr& G.-- Work Address Is to be disposed of at the following location: 4,no,;;5 +-r ►5 F rr �j �. '�c%✓1 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 5/ r9C/ .9A Signature of Applicant Date Permit No. P Atl R- 2 -n — _ _ Q x z r cP "' s - . . p - 1 W si to -- IN er- d d 1 `C 'On a p 1 ,Y; 11 •: C cyp EJ YTh H SU '.‹... a S ,z,c)r _ U x. fil .11 S' .,.... Commonwealth of Massachusetts Division of Professional Licensure 1111 Board of Building Regulations and Standards Const,* 614SuLtpp.rvisor CS-103631 t c,pires.08/30/2023 , , GREGG LACSSE, ,IIIO, 7 14 PINE ISLP@D MATrAPOIST PM 1 , (-)1V.S71 3 CW Commissioner di e ii. Fit?dize... . . • . . . • • 4 . ; . 7. • Licensee Details Demo ra hie Information Full Name: GREGG LACASSE wner Name: License Address Information ity: Mattapoisett tate: MA ipcode: 02739 ountry: United States License Information License No: CS-103631 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 8/28/2023 Issue Date: 2/2/2010 Expiration Date: 8/30/2025 License Status: Active Today's Date: 1/5/2024 econdary License Type: Doing Business As: Gregg Lacasse Carpentry tatus Chan a Reason: License Renewal Prerequisite Information No Prere uisite Information _ f No Available Documents x C 33 :C7 I :- 0. w CD CD .79 u eiswmq. c Q. 2 Cc& cat al co CD CD 040, , 5 Cry CID 8 D J `' -P- x V) .) —I O m m A !■■1` ; ■ i m > 0 0 / m m �e >' �; 0 ,eqh 3(0 k a) .. it M - ,,, , „wet AM-7 r+ MINK I ' w;