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HomeMy WebLinkAboutBLDR-24-36 RECEIVFD ------ & TWO FAMILY ONLY- BUILDING PERMIT JAN 23 2024 Town of Yarmouth Building Department ilki 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT dl By ____._ _ Massachusetts State Building Code,780 CMR Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: b Lb12.-2y -3 b Date Applied: Building 0 cial(Print Flame) Signature Date SECTION 1:SITE INFORMATION 1.1 Pro grty.Address:, 1.2 Assessors Map&Parcel Numbers / f/ (7CoV2 )t I'l y CMO� 1.1 a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear YardV7 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 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record• DAM 5-EP/iH4L/e/s L.inr4z! . w. yo<rr/OJ ,, fill") oA0,3 Name(Print) City,State,ZIP Gl/ /J��� b Jr„ head) LZ ,`cam P�RIC ,RUB 78/-563 --0059 (-met.va ari„ vC/� No.and Street Telephone Email Address J SECTION 3:DESCRIPTION OF PROPOSED WORK'(chec all that apply) New Construction 0 Existing Building El Owner-Occupied 0 Repairs(s) Alteration(s) I Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Wor 2 a}� mo .e,)(/T'finl SV,((d Q (dOd5 , pI t 14)0 /MtVet, fo/f1 f4 tnl olio's 'prn?X c e,erl d 1 ` eW e,1►ol -f aex 'o '-trrm� ,r to bOLJS L 60E& y 5V�, f e cti ri f I E�17 U VfLO b ..Uo SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ /0 tc 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier . . x 3.Plumbing $ 2. Other Fees: $ 35 L, 6t(0-1 00 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire • Suppression) $ Total All Fees:$ ✓ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ /0/OOO. 0 Paid in Full ❑Outstanding Balance Due: S -ft p LA3 o r I4 vro ter- SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) • Rvtoi.PN i,RPGieT . TR �Li d 3��>�� j� d � License Number Expir lion Date Name of CSL Holder �1�A1 L ��N List CSL Type(see below) No.and Street Type Description 1)6 X S OKy 0)-332., U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1(k2 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) 3 �6 %� RtpoLpt-1 ir.fJp/&t/r Jr �lJ8'f3 C HIC Registration Number Expiration Date HIC C msany Name or HIC Registrant Name No.and reet S Email address DUX 6 v�y rnA N332. cam 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 J OD`l L, ,V&1v'i to act on my behalf, in all matters relative to work authorized by this building permit applicatio . DAAGGI reo4SgirW W Print Owners Name(Electronic Signature) ate • 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. Ruby c.�9N&AtEk y)„..,,,,evPrint Owner's or Authorized Agent's Name(Electronic 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 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.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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 Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" -r • � The Commonwealth of Massachusetts • l /, Department of Industrial Accidents IV 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 ,f Name (Business/Organization/Individual): KV . I W&Ne Address: �/ Q.06 IL (ZUP( k j City/State/Zip: D )M3 V Ryl Mil. 0 ad, Phone #: 731 v B IN ~ 62i s Are y u an employer?Check the appropriate box: Type of project(required): I.LJ`am a employer with I employees(full and/or part-time).* 7. 7 New construction I am a sole proprietor or partnership and have no employees working for me in 8. C�emodeling any capacity.[No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. E Demolition 10 [ Building addition 4._ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp.insurance.[ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.7 Other 152,§I(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. Contractors 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. `� p i lam' u_iA/(1✓1 J 074 I Insurance Company Name: A55)CJt*7ID P 0Ynej //'/5_ co. 808X /07O 0/803-0n6 I Policy#or Self-ins.Lic.#: Wad 5OO 5)O7(0 " e O i Expiration Date: 9/7/2 Job Site Address: / 6OV r TT City/State/Zip: 10, V6 OO7/7! � 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 undern the pains and penalties of perjury that the information provided above is true and correct. Signature: (� CVVGV1't- 1 Date: /l�471/i 7�1l '"#:Phone ®/ -' 08q A 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#: 01 TOWN OF YAR MOUTH • ( _ BUILDING DEPARTMENT a� nATTACn 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 "HOMF.O R" NAME HOME PHONE WORK PHONE PRESENT MA L Ii TG ADDRESS C •R TOWN STA'l'h ZIP CODE The current exemption or `Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeo ners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as sup-rvisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of la • 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 d: ached structure assessory to such use and/or farm structures. A person who constructs more than one home in a two ear period shall not be considered a homeowner;such"homeowner"shall submit to the building official, on a foini :cceptable to the building official,that he/she shall be responsible for all such work perfonnied under the building p: 't. (Section 110 R5.1.3.1) The undersigned `homeowner' assumes respo'sibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he / she nderstands the Town of Yarmouth Building Department minimum inspection procedures and requirements an 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 equivalent. iich meets the requirements of MGL Ch.142. Yes No If you have checked ves, please indicate the type coverage by checking the app .priate box. A liability insurance policy Other type of indemnity Bo d OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have 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 1 h:homeownrlicexemp 1 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 i ( GI©©` re 1 W II9 °0 4/ Work Address Is to be disposed of at the following location: (')/1 ✓HFi6LD /IMF' 51f11/OA/ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. SY6imir-141 /2-01/..2 Signature of Applicant Date Permit No. -..x1. PA/6 s7-04) ,0i,!doo go . aXyrci< s - p ae 71x 56. "0-t 5;11 et"e. 60/g5T: memoLmi Wm/it6 D MIL /z / 1011 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 111843 03/16/2025 RUDY LANGNER RUDOLPH LANGNER JR 29 QUAIL RUN DUXBURY,MA 02332 � '�``"''zUr=�i Undersecretary Commonwealth of Massachusetts gO cRceupualationasl Laincde nSstuare ardsBoardDoivfisBiounonf Cons * visor CS-043464 Icpires: 12/08/2024 RUDOLPH L.4NGNER JR 29 QUAIL RUN CP:.14:. DUXBURY MA 02332 4b/,,,vit,0*" Asi t/1�lti s 1 I. V...,,,_.a.ti,