HomeMy WebLinkAboutBLD-23-003462 RF
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ONE&TWO FAMILY ONLY-BUILDING PERMIT e 20-2—z]
Town of Yarmouth Building Department p
1146 Route 28,South Yarmouth,MA 02664-4492 Fa RryrFNT
508-398-2231 ext.1261 Fax 508-398-0836 E.rEi
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 PImitNumber.. LiLb-A "✓740_, Date Applied:
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
1.1 PjgpergleAd u d J ca 1.2 Assessors Map&Parcel Numbers G
1.1a`Iss'llthisYan accepted street?yes_ no Map Number Parcel Number R E C q I V E D
1.3 Zoning Information: 1.4 Property Dimensions: DEC -1 qq
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) E 2 9 2022
1.5 Building Setbacks(ft)
BH4.D1Nrl a PA R TM I=.NT
Front Yard Side Yards RearYar 6Y ---
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 Cl Private Cl Zone:_ Outside Flood Zone? Municipal Cl On site disposal system Cl
Check if yes❑
SECTION 2: PROPERTY OWNERSFIIP1
21 Owner'of Record:
atN ILEA 0-2n�,� yrI2P"o-75*iPizr MA .
Name(Print) City,State,ZIP
� C6ape.. C2- 5-OF-V2•31—9573 kNDRER Two2izA6-Ztornnk.L.,ca11
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Cl Existing Building Cl Owner-Occupied Cl I Repairs(s) Cl Alteration(s)El Addition❑
Demolition Cl Accessory Bldg.Cl Number of Units_ Other Cl Specify:
Brief Description of Proposed Work':
1 °s)A E.$iSri^,b g/9TN-.4xen, 5i-bcr ON_ I)/LVt-ALL I—J Yli
0 -,fi_iP&rr`+T
SECTION 4:ESTIMATED CONSTRUCTION COSTS. G\`p
Estimated Costs: , T
Item Official Use Only
(Labor and Materials) CI
1.Building $ i 7,00 J I.Building Permit Fee:$15 C Indicate how fee is determined:
2.Electrical S 3 coo .la Standard City/Town,Application Fee
Cl Total Project Cost' I m 6)x multiplier x
3.Plumbing $ 40(t) 2.Other Fees: $ 13 53 tL
4.Mechanical(HVAC) $ List:
5.Mechanical(Fire $
Suppression) Total All Fens:$
Check No. Check Amount: Cash Amo
6.Total Project Cost $ a y 000 Cl Paid in Full CO Outstanding Balance Due: /j c)\ LI M
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) US 7065 ) -,
CS--� C� S 7.46g 3.7
License Number Expiration Date
Name of CSL Holder
)e or) S me List CSL Type(see below)
No.and Street Type Description
0101.;751 L•14,6.- U Unrestricted(Buildings up to 35,000 cu.ft.)
City/town,State,ZIP R Restricted leaFamily Dwelling
M Masoruy
0'4 . I]-3 RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Sa8.9S -; +)e no;5 ^7� c41,,i :lla�•,^t°j'" I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ..—
DrN,N'} �,�,., - I�3y > -(9- Z3
HIC Company Name or MC Registrant Name HIC Registration Number Expiration Date
Int)i--)') ) LM 3o._4wSJt�Z MA v-2-(2�1 Dcr'i r}
No.and Street 7" 1'�'"ZC ,ve i"r Zc ��,"� ""sTy-°0-_ 3/ — Email address
CitytTown,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
. 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 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.
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 I3IC Program can be found at
www.mass.itov/occi 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.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"
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The Commonwealth of Massachusetts
Department oflndustrialAccidents
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—!'F�Z6 /4i/re" //ark�/ �aY},us�,1—
Address: 7 M OL-OS7f•t":1 L. ,e
City/State/Zip: 8 Le-64570Z ; ,9. 02,631 Phone#:
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.] $• ❑Remodeling
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t g• El Demolition
4.0 I am a homeowner and Y PPerry will be hiring contractors to conduct all work on m property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I 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.t 1 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4•El Other
152,§1(4),and we have no employees.(No workers'comp,insurance required.]
*Any applicant that checks box 01 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. 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.
G/
Insurance Company Name: �iJt2 (-4 �(>1+� 1, CS,
Policy#or Self-ins.Lic.#: (7 Z Z%-)G--7 '7?(_77- -7Z i Expiration Date: 1 z-)2-Z j3
Job Site Address: J e ec2.ifib C2 City/State/Zip: / 'Q -r-
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 certif1 he pains and penalties of perjury that the information provided above is true and correct
Signature: (/ Date: Z` Zv- Z Z
Phone#: 3/Ste'
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
508-398-22311 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 ( 1 ( `' C+2 •
Work Address
Is to be disposed of oat the following location: YA‘2"°1°").714
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
Si ature of Application Date
Permit No.
,
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TTCornrnonweaIth7Mass
Pt
Division of I Massachusetts
Board Doi
Buiidin re
gProfession Regulations a Licensu and Standards
Cons tr 't�'v�i000,rvisor
CS-057268
DENNIS J LA �cpires: 02/12/2023
ZETTA
5 M �� 1
aLDSTAWLANE
BREWSTER 02631
1o7.Sv1:lcc
Commissioner dcrA
•
d." 1"-2 A
ie 6mmo-ruo-eadio-/Y
Office of Consumer Affairs and Business Regulation
1000 Washilgton Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Individual
DENNIS LANZETTA Registration: 133425
5 MOLDSTAD LANE Expiration: 06/19/2023
BREWSTER, MA 02631
CA 20M_�5�i7 Update Address and Return Card.
.��r• /Vi// //m-f /// ,
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE: individual before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
133425 06/19/2023 1000 Washington Street - Suite 710
DENNIS LANZETTA Bosto ' 02118
1`
DENNIS J. LANZETTA ' /
5 MOLDSTAD LANE 1�f C. :`/4V,,�/�'
,�
BREWSTER, MA 02631 `
Alai valid without signature
Undersecretary y
NOTICE iffNOTICE
TO TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER,2 AVENUE DE LAFAYETTE,BOSTON, MA 02111
(617)727-4900—www.mass.gov/dia
As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that
I(we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
ZURICH-AMERICAN INSURANCE GROUP
NAME OF INSURANCE COMPANY
P.O. BOX 4614
BUFFALO, NY 14240-4614
ADDRESS OF INSURANCE COMPANY
(6ZZUB-9699L75-9-22) 12-12-22 TO 12-12-23
POLICY NUMBER EFFECTIVE DATES
was
.= RUSSO INSURANCE AGENCY 45 MILFORD ST
PO BOX 637
i0mmm MEDWAY MA 02053
= NAME OF INSURANCE AGENT ADDRESS PHONE#
jEaS
LANZETTA HOME IMPROVEMENTS INC 5 MOLESTAD LANE
o
0:=MC
o= BREWSTER
= MA 02631
EMPLOYER ADDRESS
EMPLOYERS WORKERS COMPENSATION OFFICER(IF ANY) DATE
SEM MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
o� provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
,= injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
019082 w2OP1G15 TO BE POSTED BY EMPLOYER
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Fallon, Rosa
From: Andrea Worrall <andreajworrall@hotmail.com>
Sent: Thursday, December 22, 2022 12:06 PM
To: dennis.lanzetta@verizon.net; Fallon, Rosa
Cc: Fallon, Rosa
Subject: RE: building dept
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.
Please accept this email as authorization for Dennis Lanzetta to submit a permit on my address 9 Pequod Circle
Yarmouthport MA 02675.
My name is now Andrea J Worrall Cronin.
Thank you. Please contact me with any other issues.
508 2214573
Andrea
Sent from my Boost Samsung Galaxy A32 SG
Original message
From: dennis.lanzetta@verizon.net
Date: 12/22/22 11:39 AM (GMT-05:00)
To: 'Andrea Worrall' <andreajworrall@hotmail.com>
Cc: rFallon@yarmouth.ma.us
Subject: building dept
rFallon@yarmouth.ma.us
Andrea
Could you please email Rosa at the building dept and give me authorization to pull a permit on your house as well as
clear up the records listing your last name
Thank you
Dennis Lanzetta
508-958-3155
1
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