HomeMy WebLinkAboutBLDR-24-94 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department -.li
._:
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: I3(.)— a Li— Date Applied:
iC/4 '
.-.7:4-.)
Building 0 cial(Print 1,12) gna re Date
SECTION 1:SITE INFORMATION
1.1 Pro ty ddress: 1.2 Assessors Map&Parcel Numbers
via-�a, 70h La se. 31 r`
1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Pr er Dimensions:
R-zs k-3 I; 7es
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
'/4- N/A- _ IV/A-
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public(e'r Private 0 Zone: — Outside Flood Zo
Check ifyesJi Municipal❑ On site disposal system
SECTION 2: PROPERTY OWNERSHIP'
2.1 O�vpe ve_1 of ecpr _ 'sot? rides/ 1\N t. OZ/li
Name(Print) City,State,ZIPS
aI sue ► LJae
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building e Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed W rk'-:
QGrnoV �i � /h
s 'AS R _ i V r r .
SECTION 4: ESTIMATED CONSTRUCTION COSTS. FEB 5 2024
Item Estimated Costs: _ 0 ,_J
(Labor and Materials) Official Use 0 lbabi Ijt=PARTMENT
1.Building $ 1. Building Permit Fee:$ Indic B - ermine :
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cos 3 Item 6 multiplier x
3.Plumbing $ 2. Other Fees: $ em
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $
0 Paid in Full 0 Outstanding Balance Due:
.
r;t;', i
T - SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
- 0/. -6' .?3
al .sitopher V License�/(,� � Number
Name of CSL Holder
� Expiration ate
/ c1% iC List CSL Type (see below) tt-
nfoft R-6 AA
No. and Street Type Description
5- Wriltabutt, /14,4 6?64 .ef U Unrestricted (Buildings up to 35,000 cu. ft.)
City/Town, State, ZIP i R Restricted 1 &2 Family Dwelling
M Iviasonry
RC Roofing Covering
q-74-
- WS 1 Window and Siding
��� SF Solid Fuel Burning Appliances
,,�.
�-�g %PIA Ce �1�� 1�C�1'1 � • top4 I Insulation
Telephone o I
P Email address D I Demolition
. 5.2 Registered Home Improvement Contractor (HIC)
` shw2s-
ck.2 006 I/Ince/04 h� c
HIC Co pan • Name or Regis rant e HIC Registration Number Expiration Date
/ 74 /711 Alb& i s 7,147 6
N Street / 7-74 cE� cam
n
Email addr.,ss
(30.44iic .2/2. — 044.26
City/Town, State, ZIP' Tele
phone
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 permit.
rovide
l this affidavit will result in the denial of the Issuance of the building provide
Signed Affidavit Attached? Yes V No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERlMIT
I, as Owner of the subject property, hereb • authorize 0 - A
to act on my behalf; in all matters relative to work authorized by this building permit application.
Sk ( L
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 o erj m that all of tl e P p � y1 information
contained in this application is true and accurate to the best of my knowledge and understanding.
01 hoA r A- . V i hcerri- oz/g/-24-
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) Progam), 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.2ov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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. f) . 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"
• ' , I. t"I
The Commonwealth of Massachusetts
--fit ,.� Department of Industrial Accidents
°' l— 1 Congress Street, Suite 100
Boston, MA 02114-2017
,,s"• www.mass.gov/dig
«'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
Name (Business/Organization/Individual). C ' A- • Y/1ceyl�/ lh C.
Address: /I S1i1I ,gamok /2o( •
City/State/Zip: S. YGWi'kpti 1-4 A4f- OZ'FPhone #: 7 74-.242 _pg'g
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑I am a employer with employees(full and/or part-time).*
7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp. insurance required.] 8. [remodeling •
3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
4.0 I 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
proprietors with no employees. 11.0 Electrical repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions
Th e sub-contractors have employees and have workers'comp. insurance.t 13• Roof repairs
6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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.
tContractors 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: .ZCZ„u//3.--- a� /g /
Date: `Z
241
Phone#: 7 74- .2/.2 - Ogg
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 // ya. eth 4-441e
Work Address
Is to be disposed of at the following location: M .4 • taz-j:ek
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111,Section 150A.
Signature of Applicant Date
Permit No.
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