The URL can be used to link to this page

Home My WebLink AboutBLDR-24-76 ti w ONE & TWO FAMILY ONLY- BUILDING PERMIT E Ci E V D Town of Yarmouth Building Department ;:- '""� .._ -+ — 1146 Route 28, South Yarmouth,MA 02664-4492 i 508-398-2231 ext. 1261 Fax 508-398-0836 +-r `"-h1 i FEB 12 2024 Massachusetts State Building Code, 780 CMR Buildine-Permit Application To Construct, Repair, Renovate Or Demolish I BLHLDIND DEPARTMENT a One-or Two-Family Dwelling ! By -- This Section For Official Use Only i Building Permit Number: f Ltft- -`1'- i to Date Applied: G/ Buil ' g Official(Pri ame) atur Date SECTI 1:SI INFORMATION 1.1 Property Address: e i so , � 1.2 Assessors Map&Parcel Numbers / / Z.. V ssee/t. / L `� l „/ 1.1 a Is this an accepted street?yes �/ 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 Yard Required Provided Required Provided Required Provided l`) 1.6 Water Supply: (M.G.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: �� Public❑ Private❑ Zone: — Outside Flood Zone? Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1t gwner'of Recor J6 Name(Print) City,State,ZIP 0 No.and Street ` L 13 7( -3- euq�L r4 x G ,S l_lt-4 Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building( Owner-Occupied 0 Repairs(s) lV Alteration(s) l!!( Addition 0 Demolition 0 Accessory Bldg. or Number of Units Other 0 Specify: Brief Description of Proposed Work2: (Le a 0 n c B A,Ra) [( eun, ,. L j ,_% (L-LI&s' (too AI) 0 , ti .sick Oi' t/ SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ 3 I.I. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ^ 0 Standard City/Town Application Fee 0 Total Project Costt3(lt 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ `. Z ,.yam 4.Mechanical (HVAC) $ > List: O� S 3s' 5.Mechanical (Fire • Suppression) $ ` Total All Fees:$ - / 6.Total Project Cost: S3 S Q Check No. Check Amount: Cash Amount: ,/ 0 Paid in Full 0 Outstanding Balance Due: 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 Ivi 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 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: OWNER1 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. 01 4es / ACt-SIAIL 2 , ( Z ` i`/ Print Owner's or Authorized Agent's Name(Electronic Signature) 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.eov/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 Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" . The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 il Boston, MA 02114-2017 s•y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): James N Basler Address: Box 366 YarmCity/State/Zip: 6°uth Port MA Phone #: 23_ Are you an employer?Check the appropriate box: Type of project(required): 1.-I am a employer with employees(full and/or part-time).* 7. E New construction 2 I am a sole proprietor or partnership and have no employees working for me in any capacity,[No workers'comp.insurance required.] 8. E Remodeling 3.ZI am a homeowner doingall work myself. t 9. L. Demolition y [No workers'comp. insurance required.] 4,0 I am a homeowner and will be hiring contractors to conduct all work on mYP roPnY• e I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.C Electrical repairs or additions proprietors with no employees, 12.[]Plumbing repairs or additions 5.' I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other Install door 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box#i 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. lithe 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. I do her certi under the pains and penalties of perjury that the information provided above is true and correct. Signatur !� 7 — t 1-- - Z t- " Date: Phone#: v 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#: • 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 ( � U -{sy—� Work Address Is to be disposed of at the following location: Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. — / Zel Signature of Applicant Date Permit No. m g x N 2 a) 94 iD n `C OI 4 '9 O C CD 0 s (D m 5 a� n 'C N �kti v�� .r t :y:1, 111111111111111111 91111 191111111111111111, 1111 1 1111 lath 1y111111- - 'K'3 I• >,x, #1 - 'I' Xi la 111111 5..E AVMH 1H ,JNIN 01 G3AOUddVl • ..1. 2. L., a;0. t o ! _A,_ = R i a 1 A, t[ O T ^ ;i- TOWN OF YARMOUTH 1146 ROUTE 28,SOUTH YARMOUTH,MASSACHUSETTS 02664-4451 Telephone(508)398-2231 Ext. 1292 Fax(508)398-0836 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE WAIVER OF 45-DAY DETERMINATION The applicant/applicant's agent understands and agrees that due to the current declared National and State public health emergencies the determination of our Application for a Certificate of Appropriateness/Demolition/Exemption may not be made within 45 days of the filing of such application. The applicant agrees to extend the time frame within which a determination is to be made as required by the Old King's Highway Regional Historic District Act. SECTION 9-Meetings,Hearings, Time for Making Determinations "As soon as convenient after such public hearing; but in any event within.Orly-five (45) days after the filing qf application, or within such further time as the applicant shall allow in writing, the Committee shall make a determination on the application. " Applicant understands that the review of this application will be scheduled as soon as the situation allows. Applicant/Agent Name (please print):James N Basler Applicant/Agent signature: 2t812024 Date: RFCFIVFE) , ,m APPROVED OLD KING'S HIGHWAY FEB i8 O2 Y Ahi tuU I ri OLD KING'S HIGHWAY 3i2020 Application #: 94--CDOS'