HomeMy WebLinkAboutBLDR-24-231- 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
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct,Repair,Renovate Or Demolish
a One-or Two-Family Dwelling
QQ
7� This Section For Official Use Only
Building Permit Number: ,61lrt-ay'Z 3/ Date Applied:
Building Official(PrintName) Signature Date
SECTION 1:SITE INFORMATION
1.1 Propeilk Address. r l/�]�J� 1.2 Assessors Map&Parcel Numbers R E �. E I V E D
1.1 a Is this an accepted street?yes ins Map Number Parcel limbo ---
1.3 Zoning Information: 1.4 Property Dimensions: MAY 02 2024
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) -B uaDlnG DEPARTMENT
Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone:_ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY O WNERSFIlP"
21_Qw er of Record: l I I ` AR o Po , A/)/�
.._r,d',e��m �i2 1 K�— 7 tvt/ cT /,Jr'j Oo��S
Name(Pitt) City,State,ZIP
�?5 f-RiThcor- A1 3-78-596,'5-1-10 l Taro lincterpala,
No.and Stem Telephone d Address 4/Li0(Y)
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied❑ I Repairs(s)❑ Alteration(s)❑ Addition❑
Demolition Cl Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed 7/or1r2: !I/ � S[ 1Q 4�C� of
PY 5--n'n) d oc% ram? c—TX >r. /lrntse
��tCY i14 rmt
SECTION 47SS'TDIATE,15 CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ I.Building Permit Fee:$. Indicate hew fee is determined:
2.Electrical 0 Standard CityfTown Application Fee
d Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2.Other Fees:$
4.Mechanical(HVAC) $ List:
5.Mechanical(Fire $
Suppression) Total All Fees:$
Check No. Check Amount Cash Amount:
6.Total Project Cost $/J5t 000•e 0 0 Paid in Full ❑Outstanding Balance Due:
6'41
SECTION 5: CONSTRUCTION SERVICES
5.l Construction Supervisor License (CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street Type Description
i U Unrestricted(Buildings up to 35,000 cu. ft.)
City/Town,State, Zr? --- I R Restricted 1&2 Family Dwelling
lvl , 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 (MC)
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' COIYIPENSATION INSURANCE A.l; A:DAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide 1
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes 0 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: OWNER' OR A . I ' ZED AGENT DECLARATION
By entering my name below, I hereby attest it - the pa''s and penalties of perjury that all of the information
contained in this application is true and aceia o the b st of my knowledge and understanding.
0 4-/ /2.1 /1_0 2_1
`47 Owner's or Authorized Agent's Name( • onic Sign ture) Date
NOTES:
I. An Owner who obtains a building pe it to do his/her own work, or an owner who hires an unregistered contractor 1
(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.Qov/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"
O� YAK TOWN OF YAR IOUTH
cc4BUILDING DEPARTMENT
p` � =^ x 11.46 Route 28, South Yarmouth,MA 02664 S08-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
viA
JOB LOCATION: J A t 11( ILI JS- boo-mom 0_ lu c� h e '-�
NAME S ET ADDRESS SECT±'N F TOWN �/�
"HOMEOWNER" \ rn (L /Y 1 K I -5476 S !v l V�
NAME HOME PHONE WORK HONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATE 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 assessory 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 form 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 derstands the Town of Yarmouth Building Department
minimum inspection procedures and requirements d th / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFHCIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes No
If you have checked ves,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 does not have the insurance coverage required by
Chapter 142 f t Mass eneral Laws and that my signature on this permit application waives this requirement.
Ch ck one:
Sign ure of Owner o Owner's Agent Owner Agent
h:homeownrlicexemp
_-- 1 he Common wealth of Massachusetts
—"' L Department of Industrial Accidents
ai" 1 Congress Street, Suite 100
`+" =1:\ _ zi Boston, MA 02114-2017
r,sy. www.mass.go v/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/IndividuaI): , ) a v0 !Li- 1 r,2--- ,,`1 t k L-
Address: 01' z4.--+ .A.A. 0c, -- L-). i
City/State/Zip: 7L�-,� �,�a It,. 1004 ittm 026, jP^il one . l g 6. - S'f v /
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. ❑ New construction
?.❑ I am a sole proprietor or partnership and have no employees working for me in
an capacity. [�`�o workers' comp. insurance required.] S ❑ Remodeling
3. I am a homeowner doing all work myself [No workers' comp. insurance required.] t 9 ❑ Demolition
4. m a homeowner and will be hiring contractors to conduct all work on my property. I will 10 (�] Building addition
I a
ensure that all contractors either have workers' compensation insurance or are sole 11. Electrical repairs or additions
proprietors with no employees.
12. ❑ Plumbing repairs or additions
5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers' comp. insurance. 1 ❑ Roof repairs
6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 1 ❑ 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.
I. 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: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
1
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.
1 do hereby certify uttd the airs zd p- • ties of perjury that the information provided above is true and correct.
,
it S nature: Date: 2 l 2_c, 2 y
Phoney: S/ " S-9 (c 0 I
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit.License r
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 #:
I
§TOWN OF YARMOUTH
1146 Route 28,South Yarmouth,MA 02664
508-398-223!1 ext. 1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L.Ch.40,§54 and 780 CMR-Section 105.3.1.#4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at aC v`Iwioor W/ ) Li reinui{., Puri ) Mk 6 �63S
Work Address l�
Is to be disposed of oat the following location: /Q r^t c 4
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch.111,§150A.
5Jz ku2.\
Si re of App cation Date `1
Permit No.
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FlLEI 2017 1MW-6776. REGISTRY OF DEEDS BARNSTABLE CdUNTY
LYIL?AIT• COWVS&CABRAL. PC. pip BOOK 773B, PAGE UNREGISTERED LAND
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D� FIRST BANK
OWNER; VERONICA A. It rIItAULT PLAN BOOK 214, PAGE 117. LOT(S) 51
APPLICANT: JAROMIR LBW&LAMA S77LES REGISTERED LAND
DATE• MARCH 15t2017 LC PLAN. SHEET. LOT(S)
ASSESSORS MAP 741. 8&OOC. LOT(S)38 CERTIFICATF OF 7771E#
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TOWN OF YARMOUTH i. r o
1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 3 2020
Telephone(508) 398-2231 Ext. 1292-Fax (508) 398-0836 rt• °tt,;�;_,
uTh
RECE 8 tiN,,
D)KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE k�c
•
APR 17 2020
APPLICATION FOR
TOWN CLERK CERTIFICATE OF EXEMPTION
SOUTH YARMOUTH, MA
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly:
25 Dartmoor Wayassessor's map 141 t Lotrs138
Address of proposed work. MapiLot
owner(s). Jarornir Mikl / Linda Stiles Phone#:518-596-541
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 25 Dartmoor Way Year built. 1971
Email: jaromir_mikl@fulbrightmail.org Preferred notification method: X Phone X Email
f! r,t,Contractor: Stephen Duff Construction Phone#: 508-362-2707
►vlai'ina Address: 1586 Hyannis Rd, Barnstable, MA 02630 _
Email`saduffco@yahoo.com Preferred notification method: Y- Phone .Z Erna!!
Description of Proposed Work (Additional pages may be attached if necessary):
Bring to code sonotubes and framing of current backyard deck measuring 14' by 20'. Build walls
/ shed sivle roof; matching shingles like for like / roofing asphalt like for like. Install 3 Harvey
Sliders allowing for an enclosed, unconditioned 3-season room.
•
Signed(Owner or agent): 41-°adeate: I AP rd a'O01-0
Owner/contractor.%agent is ware that a permit may be requir d from the Building Department. (Check other departments.also.)
This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
i
For Committee use only:
F J �� _—_�-_Approved Approved with changes Denied
Date
Amount_s2 Reason for denial: _-- --- — r•r .
Cash/CK# _ Wt—\ —• — — -----
APR 17 Zdi d
Rcvd by. CO r'nZLii ,
�- � 14/1�ht
20-E025 - ' ' - -45,BAJiezzave,
Approved By: Richard Gegenwarth
Pate Signed: -- Via Email: 4/17/2020
APPLICATION#: c20-1 b-,l
Vozella, Beth
From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net> RECEIVED
Sent: Friday, April 17, 2020 10:11 AM
To: Vozella, Beth
Subject: Re: 20-E025 25 Dartmoor Way APR "' ?020
TOVt'' "L K
SOUTH Yf., . .uJ;ri, MA
Attention! This email originates outside of the organization. Do not open attachments or click links unless you
are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure.
Otherwise delete this email.
Beth,
I approve of the design of this 3 season room at the location of the existing deck.
Richard
On April 17, 2020 at 9:08 AM "Vozella, Beth" <BVozella@yarmouth.ma.us> wrote:
Hi Richard-
Attached is a COE for a 3 -season room at rear of house. Please review and let me know if you
approve.
Thank you,
-Beth
Beth Vozella
Office Administrator
Yarmouth OKH Committee& Historical Commission
Town of Yarmouth
1 146 Route 28, South Yarmouth, MA 02 664-445 1
Tel: 508-398-2231 X 1292
1
jaromir.mikl@fulbrightmail.org
From: Sherman, Lisa < LSherman@yarmouth.ma.us>
Sent: Friday, April 26, 2024 6:58 AM
To: jaromir.mikl@fulbrightmail.org
Cc: Sherman, Lisa
Subject: RE: Extension of Certificate of Exemption for 25 Dartmoor Way, Yarmouth Port
Hi,
Thanks - I will add this to your file.
Please let me know if you have any questions.
Best regards,
Lisa Sherman
From: jaromir.mikl@fulbrightmail.org <jaromir.mikl@fulbrightmail.org>
Sent: Thursday, April 25, 2024 5:48 PM
To: Sherman, Lisa <LSherman@yarmouth.ma.us>
Subject: Extension of Certificate of Exemption for 25 Dartmoor Way, Yarmouth Port
Attention!: This email originates outside of the organization. Do not open attachments or click links
1 unless you are sure this email is from.a known sender and you know the content is safe. Call the
sender to verify if unsure. Otherwise delete this email.
Dear Lisa:
Due to COVID-19 I would like to request an extension of the certificate of exemption, Application number: 20-
E025, which was approved on 4/1/2020. We are just restarting the exact project as we hoped and could not realize
because of COVID-19.
Thank you very much for understanding and your support.
All the best
Jaromir Mikl
25 Dartmoor Way
Yarmouth Port, MA 02675
Jaramir.mikl@fulbrightmail.org
518-596-5401
1