HomeMy WebLinkAboutBLDR-24-103- ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Buildin De artment
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1146 Route 28, South Yarmouth,MA 02664-4492 l,ft
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
( 7L1 �IThis Section For Official Use Only
Building Permit Number: I Date Ap lied:
Building Offci rint Nam gnature Date
SECTIO :SIT INFORMATION
1.1 Property Address: 'b rmCitt_tQSQ 1.2 Assessors Map&Parcel Numbers
ILA. UriA- 4 ,S
1.1 a Is this an accepted street?yes no Map Number Parcel N mRr E C F I V c D
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontag (ft) FEB 2 6 2024
1.5 Building Setbacks(ft)
RIM DINGFPARTIyIENT
Front Yard Side Yards I _
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 Private❑ Zone: _ Outside Flood Zone? /
Check if yes!: Municipal❑ On site disposal system EI
SECTION 2: PROPERTY OWNERSHIP'
2. er'of eco'Pd:
J f t re:--Iy. 1.,4/ek 1)e5 "4 na Z A 0- 6 7-1Name(Print) City,State,ZIP
2 itholi91lsc 40.aA V r 6f7- o& c s __ , 10-'e//4 ev'.Yii3Oe-X-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED (check 1 that apply)
New Construction❑ sting Building i�Owner-Occupied Repairs(s) Alterations VAdd'( ) Addition 0
Demolition of Accessory Bldg. ❑ Number of Units I Other 0 Specify:
Brief Descriptioc of Proposed Work2: 2-kr V 1 Y O - V p/�. b r: z ` ft E>
�mdl b � 1s3 V_ 4 C r 1—e
A 1 3 a ?-�%v c.c -4,`lF-s 0- ,}.mac-iGp ,,,".
Grn SG +w..2 pf 0 '
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ .R F, 000 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ / r ��U 0 Standard City/Town Application Fee
l� 0 Total Project Cost'(Item 6)x multiplier . x
3.Plumbing $ Cj 1 aDU 2. Other Fees: $
4.Mechanical (HVAC) $ List: Va,AO )sh
5.Mechanical (Fire •
Suppression) $ Total All Fees:$
6.Total Project Cost: $ 5 10 a c> Check No. Check Amount: Cash Amount:
0 Paid in Full 0 Outstanding Balance Due:
.,- -
�SGS IS 833
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
CS -- 1 6 ce) j c6
:12_--c 2- Li
'� r� f�'\._ License Number
Name of CSL Hn\ 0 o er E iratio Date
, 0 P k 1 €. _fType
� � �T List CSL (see below)
te o. and Street
Type Description
r 1 W M U Unrestrictedc !`� '1 (Buildings
City/Town,
i �T � �. �� ( g up to 3 5,000 Cu. ft.)
ty own, State, ZIP R Restricted l&2 Family Dwelling
M iviasonry '�
RC Roofing Covering
WS Window and Sidin•
11 C-_ P42bv IcAte r 4 SF
() _��ti _ j- � Solid Fuel Burning Appliances
Telephone 7� Lf) �'� - I Insulation
pone Email address
roveru D Demolition
p ent Contractor (HIC)
Nn/ ) Tr 3 L--) 1 2._ lei_e___V3:6 -). . 2"-
5.2 Registered Home I
VI leN 11-\ p__01, ci2 h-lele < ... .
qi
HIC orn an Registrant Name
ompany Name ame 4?" HIC Re HIC Registration Number Expiration Date
1.- - kNI
o. and Street frc&s'�
IQr� CQ * }-twe#
13( r in� .h i iv0V 0 2- 6_S6 Ser.-504 -- r Email address
City/Town, State, ZIPTelephone
SECTION 6: WORKERS' COMPENSATION 1NSLTRANCE
AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed
this affidavit will result in the denial of the Issuancep and submitted with this application. Failure to provide
of the building permit.
Signed Affidavit Attached? Yes 0
No , 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED
OWNER'S AGENT OR CONTRACTOR APPLIES WHEN
FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorizeIv\ , ., rr,
H
to At on m behalf, A }�,
Y al a er elative to work authorized by this building permitpp a lica
1,44,d Lion.
fi
0‘ er's Name (Electronic Signature) °tT/Zai
of
Date
SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLA
RATION
By entering my name below, I hereby attest under the pains and penalties p n Ides of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
01\0 \'\\/\ fV\ i 1--/-2�11rv� f6-i �
Print Owner's � . �� `�'
or Authorized Agent s ame (Electronic
,. ( Signature) Date
NOTES:
1 . An Owner who obtains a building permit to do his/her own work, or an
(not registered in the Home Improvement Contractorowner who hues an unregistered contractor
P (HIC) Prog1-am}, will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Pro gam
www.mass.gov/oca Information on the Construction Supervisor �' m can be found at
p sor License can be found at www.mass.Qov/dps
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) ge(including garage, finished b
�- � � 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"
o.o'd\
• The Commonwealth of Massachusetts
1 •V= 1
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" 1� Department oflrtdccstria/Accidetzts
W 1 Congress Street, Suite 100
j S Boston, MA 02114-2017
to s www.ma ss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A I •licant Information
Name (Business/Organization/Individual): !�I _ Please Print Letibl
Address: (7 0 P 1 firNP>`1s
City/State/Zip: M PI U ZG O
Phone #: S-ag— C l i — 6 J 2 9
Are you an employer?Check the appropriate box:
1.0 I am a employer with employees(full and/or part-time).* Type of project(required):
7.
2. I am a sole proprietor or partnership and have no employees working for me in ❑New construction
any capacity.[No workers'comp. insurance required.] 8. lZr emodeling
3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t (rjQ�/
9. Demolition
4.0 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 1 0 El Building addition
proprietors with no employees. 11. Electrical repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.:
13.Q Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees. [No workers'comp. insurance required.] 14'❑Other
"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. 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:
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 their formation provided above is true and correct.
Li
Signature:
Phone#: 5 c — 34.E-) — 0 ZC> Date: 2`/ 2 � �vZ
0
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 OQ MG- � Se VA v
Work Address
Is to be disposed of at the following location: f rcr ►S�n c,I P1
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.
\
0 H n Commowealth ot Massachusetts
Division of Occupayonal Licensure
Board of Buildmg R .,: vfations and Sta:ndards
Coos i:...• F..:.E1 odri SlOgvisor
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THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs & Business Regulation:
HOME IMPROVEMENT CONTRACTOR
TYPE: individual
Registration
i '73492
MOHHMED RAHMA.N
DIB/A ALL CAPE: BUILDERS
MOHHMED RAH MAN
70 OLD PHINNEYS LN
BARNSTABLE, MA 02630 ,
Undersecretary
Registration valid for individual use only before the
expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston„ MA 02118
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Not valid without signature
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Fixture Location Glass Front&
24"Shower II
New Toilet Centered on
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