HomeMy WebLinkAboutBLDE-24-970 (2) ;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 �s
Massachusetts State Building Code,780 CMR =xy'
Building Permit Application To Construct, Repair, Renovate Or Demolish �ob�^
RPORATSO
a One-or Two-Family Dwelling
This Sectio For Official Use Only
Building Permit Number: 8ibic:7,4. Date Applied:
Building Official(Print Dame) ignature Date
SECTIO 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
-'1 C vT l f.r.J/ v`4
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O ner'of Record:
,p 03 lit On 1". /Ceti/0/?-in Sp, // vi
Name(Print) City,State,ZIP
500 pi'e''efrfh i081001ik Aiqb.yo#,P4i 3L/M�c. (P�
No.and Street Telephone Email Ad ress
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work'-: p 1004 SA • ue "01s1 u.'A f 74,.. is/ re,v oh ',i
7 J Arioni s 2.14 ' c ho•iillr Poo* . ;
RECEIVED
SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only JUL 12 2024
(Labor and Materials)
I.Building $ 1° St90 1. Building Permit Fee:$ Indicate how f kde_ut RTM ENT
0 Standard City/Town Application Fee
By:
2. Electrical $ �JSOD 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ rj,ppd, 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
q Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ,, p7/ do o. 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 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 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(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 ❑
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.
T94,as fl.S a- 9-/2 --211
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 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
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
9P-110.i _4' Office of Investigations
—" Lafayette City Center
psi .. =
�!,'�ty 2 Avenue de Lafayette, Boston, MA 02111-1750
. r
w 'ss www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): c'-f7/ Dj /1/v4 ✓a
Address: -ie90?2,'h s•r,a// v1 ya.1,14 aa-A )14 ' %2‘6Lr
City/State/Zip: Phone #: 5 O g „(2 a .21/c
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ 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. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [emodeling
ship and have no employees These sub-contractors have 8. n Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
/equired.] 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions
3.Kli I am a homeowner doing all work officers have exercised their I I.n Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL I?.n Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13 n Other
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).
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 1— /1— .2 Ls
Phone#: c Oes?to nsS
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 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing
Inspector 6.DOther
Contact Person: Phone#:
TOWN OF YARMOUTH
Office of the Building Commissioner
4 o` 1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1260 Fax 508-398-0836
.l Nco , 7
�ti;�A�ORA
HOMEOWNER LICENSE EXEMPTION
DATE:
JOB LOCATION: 7iiIt9S /V"A°2 -/ceiof2i•1 5rn20ed Pro-opalti
NAME STREET ADDRESS SECTION OF TOWN
HOMEOWNER T201cS /1/4Ars 5-08J80 3/c
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS S`'"'^e
CITY OR TOWN STATE ZIP CODE
Definition of Homeowner:
Person(s)who owns a parcel of land on which he or she resides or intends to reside,on which there is or is intended
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 c7/,
TOWN OF YARMOUTH
Office of the Building Commissioner
Yarmouth, MA 02664
1146 Route 28, South
508-398-2231 ext. 1260 Fax 508-398-0836
_ RPQRAtEO -..:
DEMOLITION DEBRIS DISPOSAL APPLICATION
Pursuant to M.G.L. c.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. ` -41. + -
4 ca,724.0 sm ?I/ rd
Work Address
Is to bedsp disposed of at the following location: S 2 Jc Ak t cd
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, § 150A.
Signature of Applicant Date
Permit No.
T -0...10pr -."1111111W .
.
.. .
f•
\ems,
) _
/:\ 1' -).7.1111.14111110 Al .
1 8_011 kgpvm _
willmiramliriiimassocimmormarls-Z-
• ._
/Q0iltiti
ap,
r
..______
aNIIIMOM i 11.... ••.•1144,•+•• 15
i r
-
671-ck
11
, t
LP viols
,
. .
..4,, -. cie.€_k
1 ___
7 .... _ _
i .
. . ,
ktrobvt
s'Deft.
fr--
. r
L i
111
,
1
4
I
—