HomeMy WebLinkAboutBLDR-24-259 J
ONE & TWO FAMILY ONLY- BUILDING PERMIT
...
Town of Yarmouth Building Department r
1146 Route 28, South Yarmouth,MA 02664-4492 � !� _
508-398-2231 ext. 1261 Fax 508-398-0836 f ; .�`' ■
Massachusetts State Building Code, 780 CMR „i
o.oe
Building Permit Application To Construct, Repair, Renovate Or Demolish j
a One-or Two-Famil Dwelling ~ r
y
� a
This Section For Official Use Only
Building Permit Number: 6(m2,,,24..a5-9 Date Applie :
Building fliciai(Print ame) rgnature Date
SECTI 1:S INFORMATION
1.1 Pr rty Addres 1.2 Assessors Map&Parcel Numbers
�' kr CAS �e, -ve
1.1a Is this an accepted street?yes V no Map Number Parcel Number ,
CEIVED
1.3 Zoning Information: 1.4 Property Dimensions: RE
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) MAY 2 0 224
1.5 Building Setbacks(ft) i{
Front Yard Side Yards Rear ,RIJILDING DEPAIRTMENT
�,
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 0 Private 0 Zone: Outside Flood Zone?
— Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.�p wner'of Record: S
_L7� S 0i—&tlVi E kOr.A606id.5/Ar °' Ct✓014— "1A a z (v(o cl
V Name(Print) City,State,ZIP
ere +s/^..,.3 • ,- 41-7_78o-ipt ek v►-r,170(A1,4S 0—g.P,4;(. ramelx
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building V Owner-Occupied 0 Repairs(s) V Alteration(s) 0 Addition 0
Demolition 0 1 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description f Proposed Work'':
/ R J ro wl o °art:, - r2 ,
n Pe N4id4 aitd (4Pd I (i-,Nvoit
SECTION 4: ESTIMATED CONSTRUCTIONCOSTS
Item ! Estimated Costs: Official Use Only
(Labor and Materials)
t7 1.Building $ !q,Oa 1. Building_Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2. Electrical $ 15 Oa, 0 Total Project Cost3(Item 6)x multiplier x
Plumbing
3. $`0/WO 2. Other Fees: $
✓--4. Mechanical (HVAC) $ 3‘000 List: _3 s:OD C .374r
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
Lv 6. Total Project Cost: $ iSD NO
0 Paid in Full ❑Outstanding Balance Due:
f.
1
SECTION 5: CONSTRUCTION SERVICES
5. 1 structio❑ Supervisor License (CSL) OS 0.1 it7g16-°
1 �v (\v1 CA) } v' , License Numberir t 5
s pir tion Date
Name of CSL Holder
---Z- t Cz, -
List CSL Type (see below)
' \ `e.....
No. an , treet — Type Description f t/
V02,. yV
LT c✓ Unrestricted (Buildings up to 35.000 cu. ft.)
iry ed 1PDwellingoR Restricted . &2 Family
Ci y/Town. State; ZIP 1 Masonry
RC Roofing Covering
Vv'S t Window and Siding
SF Solid Fuel Burning Appliances
S--- 7 — yC4 c .1 & 00 414/ I Insulation
1
Telephone Email addres D Demolition
5,2 R/ ----. )egistered Home Improvement Contractor (HIC) i f
L; „di ( i r7 14 3 g 7 -7 0
' L3frati a ‘
HIC Registration Number xpir Lion Date I
HIC Company Name tor HiC Registrant Name
Z t kaxive I Vci.vv4-6, lie
, htv . eoetit,
?�o .d S t
'6 rxiii oz&V/ a0 �, y .2-7Email a ress
City/Town. State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION T EVSUR�CE AFFIDAVIT (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. !
1
Signed Affidavit Attached? Yes 0 No C►
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i
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 Owners 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
conta. m : is lication i e and acc to the best of my knowledge and understanding.VZ4/ 7
i .1 t Owner's or Authorized Agent's N' e (Electronic S inC'_ture)
ate
NOTES:
1 . An Owner who obtains a building permit to do his/her olAm 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 rind under I.G.L. c. 142A. Other important information on the HIC Prow-am can be found at
w-ww.mass. gov/oca Information on the Construction Supervisor License can be fod at u-ww.mass.Qovv., dos
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) (including garage, Znished basement/attics, decks or porch)
count
Gross living area (sq. ft.) Habitable roomt, Number of fireplaces Number of bedrooms I
Number of bathrooms Number of half/oatis
I
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 Common wealth of Massachusetts
I Department of Industrial Accidents
' ( i 1 Congress Street, Suite 100
1
q a Boston, MA 02114-2017
` �sr•-. 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): ()h S YK(../(4im C'
L."-
Address: 22 lCcU ce / L !/
City/State/Zip: I..O71;CZ r)),1 £27 Phone #: 50 yiy- rpx3 t/
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 modeling
3.E I am a homeowner doing a!i work myself. [No workers'comp. insurance required.]-19. Q Demolition
4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.Q 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.! 13•Q Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per NIGL c. 14.El Other
152,§1(4),and we have no employees [No workers'comp.insurance required.]
*Any applicant that checks box RI must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they are doing al!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: 455 cC.'a tei E.r'') e
fo � �h . t/
� y
Policy#or Self-ins.Lic.#: 4jC L Sa O S0 t l LS7) i 't 3 Expiration Date: /D/ZZ40 Zti I
Job Site Address: (' &ye_ I'sk —tea City/State/Zip:S er,itcs�, I A (�
Attach a copy of the workers' compensation policy declaration page(showing the policy numl5er and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00
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 ce ' under the pains and pen 'es of perjury that the information provided ab ye is true and correct.
Signatur . Date: S Zr-1 -Z
Phone#: 92i5 r3'y- 'Q3�
i
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 YARM'IOUTH
�° BUILDING DEPARTMENT
A;gcnec.r/_`') 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCA 1 ON:
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNE "
NAME HOME PHONE WORK PHONE
PRESENT MAIL G ADDRESS
CITY O• TOWN STA 1'E ZIP CODE
The current exemption fo 'Homeowner' was extended to include owner—occupied dwellings of one or two units
and to allow such homeown-rs to engage an individual for hire who does not possess a license,provided that such
homeowner shall act as super,.sor. (State Building Code Section 110 R5.1.3.1)
Definition of Homeowner:
Person(s)who owns a parcel of land . t which he/she resides or intends to reside,on which there is or is intended to
be, a one or two family attached or det. hed structure assessory to such use and/or farm structures. A person who
constructs more than one home in a two- ;ar period shall not be considered a homeowner; such"homeowner"shall
submit to the building official, on a form ac.-ptable to the building official, that he/she shall be responsible for all
such work performed under the building.pe t. (Section 110 R5.1.3.1)
The undersigned 'homeowner' assumes responsi.'lity for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned 'homeowner' certifies that he / she um' rstands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and th:t he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OI~r1CIAL
L\ISURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which aeets the requirements of MGL
Ch.142. Yes No
If you have checked yes, please indicate the type coverage by checking the appropn:to box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insuran• coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application wai*-. is requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
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 certifythat the debris resulting from the proposed work/demolition to be
/
conducted at ( ' &f.L isk�� S L/lvncal
Work Address
Is to be disposed of at the following location: Sod �xr•D L�-
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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Commonwealth of Massachusetts
F
Division of Occupational Licensure
111 Board of Building Regulations and Standards
I Li
Cons ion sup9rvisor
CS-079685 14,0
/•
spires: 07/05/2023
BRIAN WOOOILL JW
22 LAUREL LANE
•
FORESTDALt MAL
/
PiNsigter
Commissioner dect8G
ro,92/-nevoivead e/Aez,),,iezeie4m/Z)
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE: Individual
Regigiakin Expiration
[1788 09/14/2023
BRIAN WOODIEç
D/B/A B.W. CON - „ CtilORTB
•
BRIAN WOODIL .i/z/
22 LAUREL LANE, .••••74.
FORESTDALE, 6264-e"/
Undersecretary
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