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Home My WebLink AboutBLDR-24-386 ' RECEIVED JUL 17 2024 O vS & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department O'F YAK BUILDING DEPARTMENT 1146 Route 28, South Yarmouth,MA 02664-4492 0 508-398-2231 ext. 1261 Fax 508-398-0836 q 41 Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish ~°„RpoRATEo`b- a One-or Two-Family Dwelling .----- ' This Section For Official Use Only Building Permit Number: 1 14. 1..a C..3b Date Applied: • / . Building O al(Pnnt N e) n re Date SECTI 1: SI INFORMATION 1.1 Pr �ty Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 0- i MOO 20 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard 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 0 Zone: Outside Flood Zone?Check if yes!: Municipal 0 On site disposal system X SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record a /) Name(Print) City,State,ZIP a /,V,4/-r2n IQG 5( -3 9 - Y0-76 1I mart?) 1023tOr. - asyma No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) OA3 f#() rr, ,/l New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) Ili( Addition 0 Cam' 1 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Descri tion of Proposed Work': &)(GkaY1 q e L{'/ n oiL re.a(aa. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ 6,000 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ j,DOD 2. Other Fees: $ 3� (` 3 i^ 4.Mechanical (HVAC) $ List: �/ I , 5.Mechanical (Fire Suppression) $ Total All Fees: $ 6.Total Project Cost: $ Check No. Check Amount: Cash Amount: 6, 000 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) License Number Expiration Date Name of CSL Holder List CSL Type (see below) No. and Street Type Description U Unrestricted (Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling City/Town, State, ZIP M 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 (HIC) HIC Registration Number Expiration Date IIIC Company Name or HIC Registrant Name No. and Street Email address City/Town, 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 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 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. /an'e.2. jai iti7,7) 1;? -/ /7-• Print Owner's or Authorized Agent's Name e-ctronic Signat re) 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 HIC Program can be found at www.mass.go\ 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 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 Department of Industrial Accidents 9, . Office of Investigations Lafayette City Center - , 2 Avenue de Lafayette, Boston, MA 02111-1750 '`'Ms. www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Jar). I nil 0r-4- i Address: 033 Lk)Gt-Y'r \ JZo Ci d City/State/Zip: (L(t'vl0 Lt '-/h pc,r Phone #: 5 o &- 3 ci y-- S'10 Are you an employer. heck the appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.[( I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#l 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. 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties of perjury that the information provided above is trite and correct. ti , Signature:�__._ 1. t/if_ � ��t_6L- Date: "1-17- ZV Phone#: 5O6 c-1 91/- /5/O Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 3EICity/Town Clerk 4.0 Electrical Inspector 5DPlumbing Inspector 6.0Other Contact Person: Phone#: TOWN OF YARMOUTH ,og A � Office of the Building Commissioner ` 1146 Route 28, South Yarmouth, MA 02664p -' ,y t �' 1 508-398-2231 ext. 1260 Fax 508-398-0836 4 `: 4GM[cac V..CofF0RnlEo s?�.. HOMEOWNER LICENSE EXEMPTION DATE: JOB LOCATION: a3ZV (KVer/ qC/. et ��(l !97 NAME i n STREET ADDRE� CTION OF TOWN HOMEOWNER 1,0r)iA' J/ort)n 268'c} 6/O NAME HOME PHONE /� WORK PHONE PRESENT MAILING ADDRESS 123 Warr6rl "Q ad /1 lorc ror/- 414 zi 3 CITY R TOWN - STATE ZIP CODE Definition of Homeowner: Person(s)who owns aparcel ofland on which he or she resides or intends to reside,on which there is or is intended 1 to be, a one or two family attached or detached structure accessory to such use and/orfarm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of780 CMR 110.R5,provided that if a homeowner engages a person(s)for hire to do such work, then such homeowner shall act as supervisor. This exception shall not apply to the field erection of manufactured buildings constructed pursuant to 780 CMR 110.R3 The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws,rules and regulations,and certifies that he or she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that he or she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE qa41-11- i"ildi- IiIIIIJIIFI ; I: 1. 11 11,1111: e, ri