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Home My WebLink AboutBLDR-24-163- _-, ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department • ;.•' '"� ._ 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 't �„ ' ■ Massachusetts State Building Code, 780 CMR °, e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: et fi- ).' —'ki`3 Date Applied: .2 ‘X.14 4 Building Omcial(Print e) ' ature Date SECTION :SITE NFORMATION 1.1 Pro er dress: 1.2 Assessors Map&Parcel Numbers 1 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: E r Zoning District Proposed Use Lot Area(sq ft) Frontage R C L V "' 1.5 Building Setbacks(ft) uu Front Yard Side Yards �— ke YaiMAR 05 20211 Required Provided Required Provided Required itittivilWARTMENT 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 bY5:7 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP1 1 neri of Recor iICiMILO I ree.).0 I At: (Di,.yred-) X. a 29G 1 Name(Printt)(/� City,State,ZIP AM ( u_j.i7 re") Sr jU8— -94.2e 2 cc, -i Dftsdi vspCeawe-tsr ,c t7-, No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building❑ 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 rk2: Ni XJL SI/4DO•,C pir-At fr , .!x4. . rugs €.arts !x/OK.4( Flz.+�cs. SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ f,6;6e0 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ �� 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ �t {� 4.Mechanical (HVAC) $ List: ID U•D(f etA.S /1 5.Mechanical (Fire $ _ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 262t) 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5. truction Supervi 1 nse (CSL) ck-C-j E-f'/�V1.�0 / UDC, /� License C5 -�Number Expiration Date Name of CSL Ho de List CSL Type (see below) 'V , L''LLrI /I TO -J T—, - No. and Sire Type Description 0 i'�u�J CZ_ ,y U R Unrestricted (Buildings up to 35,000 Cu. ft.) �" Restricted I &2 Family Dwelling City/Town, State, ZIP M Masonry. RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation ' Telephone - p Email address D Demolition 5.2 Registered Home Improvement Contractor (HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No. and Street Email address City/Town, State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (iYI.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 . ❑ 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(iunde !pains and penalties of perjury that all of the information tained in this application is true and accur. ./ - e • . t o my ow ledge and understanding.Dia g...) lC14�l V UeCiw i Airy ------cm=s------) 63- 0 - 20 Print Owner's or Authorized Agent's Name lectronic Signature) Date C NO 1T ES: 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.gov/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 1 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 1�—go—. I Department of Industrial Accidents it RI011. 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 Name (Business/Organization/Individual): l G HA-g j L e,,�4 V Address: /7 jitAckiE.fo s City/State/Zip: W�Sr �, ,,,c r,t /�(�. , Phone #: - - P4. Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. El New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in ca aci S. ❑ Remodeling n • y p ty.[No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]r 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 11.❑ Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 ❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 1 •❑Roof repairs 6.0 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 .:y of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ,- th p ins, s- alties of perjury that the information provided above is true and correct. I Signature: (r C � Date: � 3-,3 - 1 Phone#: 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 1./ 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 osed work/demolition to be t� conducted at 2 i jk els pa ,f.y0 Work Address Is to be disposed of at the following location: -40 9- ,t,L Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. J-& -#2f Signature of Applicant Date Permit No.