HomeMy WebLinkAboutBLDR-23-12991 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department
1146 Route 28, South Yarmouth,MA 02664-4492
''',-4:44' : ')\ '
508-398-2231 ext. 1261 Fax 508-398-0836 14
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: ..DA- 23"/199/ Date Applied:
i ,M SPAT )- 1L
Building Official(Print Name') I
Sign re Date
SECTION 1:SITE INFORMATION
1 1.1 Property A dr s: 1.2 Assessors Map&Parcel Numbers
2-- Grij/.e�� Coved" e,.21 a2/4
I.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
10, .tc2
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 0 Private 0 Zone: Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.' ' 'wne oLRecord:
1
� i ame(Print)1 / 14 Leo €s " Y - Li /174- O.)473
City,State,ZIP
No.and Street Telephone Email Address GOM
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) /
New Construction 0 Existing Building 0 J Owner-Occupied ❑ Repairs(s) 0 I Alteration(s) Q Addition
Er-
Demolition ❑ Accessory Bldg. ❑ Number of Units Other 0 Specify':
P fY':
Brief Description of Proposed Work': �xe ,tag jo, ,,t..- Cj I L
b0J HPatt7i-a-,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ ye 000 1. Building Permit Fee:$3So Indicate how fee is determined:
2.Electrical I 0 Standard City/Town Application Fee
3,ow)
3. Plumbing $ 0 Total Project Cost3(Item 6)x multiplier x
3 Sva 2. Other Fees: $ 6Q C37j
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire
Su ression) $ Total All Fees:$ - -
6. Total Project Cost: $ Lt f Check No. Check Amount: �`��
I R 0 Paid in Full ❑Outstandin
e '
OCT 2 6 202
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Name of CSL Holder License Number Expiratio Date
List CSL Type(see below) V
No.and Street Type Description
�✓� r j U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/To n,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
3-- "�3ef / - �uoce,w7Wh SF Solid Fuel Burning Appliances
O� ef '' I Insulation
Telephone
Email addr2s eep D � Demolition
5.2 Re ' ed Home Imp ove ent Contractor(HIC)
4114.0
HIC Comp e or C Regi ant Name HIC Registration Number Expiration Date
rro.and Stre t gf,Gpes9- � �e)100d,6Lt/s-7
:Ug'ry e-401 1 I Emai ddress
City/To , 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 ltiii
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 accurat to he best of my knowledge and understanding.
147
to*boa
Print Owner's or Authorized Agent's Name(Electronic Signature)
Date
NOTES:
permit
An Owner who obtains a building 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
wtivw.mass.aov/oca Information on the Construction Supervisor License can be found at www.mas� g
2. When substantial work is planned,provide the information below: ov/dos
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'
h
The Commonwealth of Massachusetts
•
1 �
�� /
Department oflndustrialAccidents
�:.i 1 Congress Street, Suite 100
'= Boston, MA 02114-2017
all www.
mass.a ov/dig
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
�it.CC-�
Address: it---045 / /
City/State/Zip: (itJ•e! ' he � � 'phone #: SDI-JQ
"d 4f
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑I am a employer with
employees(full and/or part-time).*
2❑I am a sole proprietor or partnership and have no employees working for me in 7. ❑New construction
any capacity.[No workers'comp. insurance required.] 8.
[remodeling
3. am a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. [1] Demolition
4.illI 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 10 uilding addition
1 l. 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.E Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.:
13.E Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. ❑
152,§I(4),and we have no employees. [No workers'comp. insurance required.] 1 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
r 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.
Insurance Company Name:
Policy#or Self-ins.Lic.=:
Expiration Date:
Job Site Address: CA
City/SAttach a copy of the workers' compensation policy declaration page(showing the tpol policy number and ex iration
4110T
Failure to secure coverage as required under MGL c. 152, cration date).
and/or one-year imprisonment, as well as civil penalties in§25Ahe form of STOP WOnal RK ORDER punishablen nd a ne of up
to
$2 00.00
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
a
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature:
2g Date: AO 44 oft Phone T i '. _: 6oZ
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
g Permit/License#
Issuing
b 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#:
o R,t TOWN OF �'ARMOUTH
s' O'
o(. -. BUILDING DEPARTMENT
;� a.,<<,,,,�,• '',d 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DA 1E:JOB LOCATION: �i / 4.4- Pj ,0 &W Xe*--eviA
NAME STREET ADDRESS SECTION OF TOWN
::HOMEOWNER" 5/4at,.e raR .?� 9—6,) g-
NAMF HOME PHONE WORK PHO
PRESENT MAILING ADDRESS 2, i,, --v.:1 4 c-/- 6Je5r
CITY OR TOWN STA IL 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_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 fouuu acceptable to the building official,that he/she shall be responsible 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 and
requirements.
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements
Ch.142. Yes No q of MGL
If you have checked yes, 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 doesnt have the insurance coverage
Chapter 4 of the Mass. General Laws and that my signature on this permit application waives thisre qu requiredmt.
requirement.
Signature of Owner or Owner's Agent '' e.
b 0�•ner Agent
h:homeownrlicexemp
tom.
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 resultingfrom the proposed work/demolition to be
conducted at g` ''L15h, G/
Work Address
Is to be disposed of at the following location: Art-'1404 Aire45,0.1' I
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
P (a.
Signature of Applicant Date
Permit No.
ei
/` ,
ONE or TWO FAMILY- BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
i
Address of Proposed Work: e L v 1(,, LcaA, C 4
Scope of roposed Work: /,' X r� x/ I' Jr -eCl 7io?
:6 ,7
Date: W:no/.1-el 3
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.
Receipt c/k�'owled ement: 4(e/del-i
Applicant's Signature Date
Rev. March 2022
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