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Home My WebLink AboutBLDR-24-34 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department #6� 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: 6L.6 I f�L_2q-3(4 I Date Applied: , —,/,(14 Building Official(Print Name i attire Date SECTION 1:SI E INFORMATION R1.1 Property Address: 1.2 Assessors Map&Parcel Numbers C' IV D 1.1 a Is this an accepted street?yes 7 no Map Number Parcel Numb r JAN 217024 1.3 Zoning Information: 1.4 Property Dimensions: L Zoning District Proposed Use BUILDING DEPARTMENT P Lot Area(sq ft) Frontage(ft) By _.__,_____ 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public i7 Private 0 Zone: Outside Flood Zone? Check ifyes❑ Municipal 0 On site disposal system Re SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record Th —a E le it,"tie AL i Z, O. Vi91l.1V l,L.a 1--% .. ,11,9 c /s 3 Name(Print) City,State,ZIP il a ..„„se... , l3 Ad No.and Street R� - - s 6r , r�� Telephone Email Address / SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Buildings Owner-Occupied Ip Repairs(s) 0 Alteration(s)Xl I Addition ❑ Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: saw) SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ /Q D D O. Of7 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee 3.Plumbing 0 ❑Total Project Cost I em 6)x multiplier x $ 2. Other Fees: $ 2� ''ll 4.Mechanical (HVAC) $ I �� .7��v /`DOO, 60 List: _ 5.Mechanical (Fire Suppression) $ Total All Fees:$ 6.Total Project Cost: $ II/ oo Check No. Check Amount: Cash Amount: 1 I ODO 0 Paid in Full 0 Outstanding Balance Due: Fir soz 6c baafz_ g g oleo/ , c67m 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 Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry • RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date No.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 ❑ 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 gains and penalties of perjury that all of the information contained in this application is true and accurate .est of m •knowledge and understanding. / 'O Z.-, E'>�JA 2 i I Z dr` _Air-,,,,-- ' / /,2 a �v, L/ Print Owner's or Authorized Agent's Name(El= tonic :ignature) 0 t/ D e 7 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 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.) (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 / Number of half/baths / Type of heating system oh-e,� 4, Number of decks/porches I Type of cooling system Ro,tZC6.D Al dL Enclosed Open ✓ 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts ��9;,> ►,� Department of Industrial Accidents �r I Congress Street, Suite 100 47. Boston, MA 02114-2017 IMP_�•'• www,mass.go v/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): 1,2 Address: +--j L-04 Jll City/State/Zip: 0. ,l�pr2movr Phone #: Spg Are you an employer?Check the appropriate box: 8N.2'3 Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.C 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. [No workers'comp. insurance required.]t 9. El Demolition — 4.r.sI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole I 1•[ Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0Plumbing 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.El 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. 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: 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. 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify u to pain an ens t/ of perjury that the information provided above is true and correct. Signature: Date: //�9/�dtf'. .:)/ Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: 01..YA t� TOWN OF YARMOUTH BUILDING DEPARTMENT x-( 4- ci ATT,. .-,F•ti�o 1146 Route e .1Q Yarmouth, �� R 28, South MA 02664 508-398-2231 ext. 1261 PLEASE PRINT: HOMEOWNER LICENSE EXEMPTION DATE: //2',-l2-oatf JOB LOCATION: '19' ,ee.c, LA. . NAME �'4�rr"�t'v%z‘. STREET ADDRESS SECTION OF TOWN "HOMEOWNER" 1441 2 V .D 8 Aid rt 6-o - 'q _$/ /.ri c,ay.. e- NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS W q C 2 en-lerE k A �w Qn�1�►�rt.� yJ��4 CITY OR TOWN rn.ro' 3 STA LE, ZIP The current exemption for 'Homeowner' was extended to include owner-occupied dwe1ODEof 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_y 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 foiui acceptable to the building official,that he/she shall be responsible for all such work perfoi wed 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 Du ment minimum inspection procedures and requirements and that he / she will comply with said procedures and requirements. -------p jd HOMEOWNER"S SIGNATU APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a curren .ability insurance policy or its substantial equivalent, which meets the requirements Ch.142. Ye No of MGL If you have checked ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy LJc S Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage re uir by Chapte - of the Mass. General Laws and that my signature on this permit application waives this requirement.ed / 4 unite ' MI igna ire of 0 • '''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. 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 to C osE 4.) Work Address Is to be disposed of at the following location://3ie/YlovrZz_ si�2 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 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