HomeMy WebLinkAboutBLDR-24-369 RECEIVED
JUL 10 2024 NE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department p'F ` ,
BUILDING DEPARTMENT
By. ^ _ 1146 Route 28, South Yarmouth,MA 02664-4492 - p
508-398-2231 ext. 1261 Fax 508-398-0836 r 7" 7 1
Massachusetts State BuildingCode,780 CMR O ',Y y
1 _,
Building Permit Application To Construct, Repair, Renovate Or Demolish . M�rr"`"""
~'• -RPORAto�b5
a One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 4-�( Date Applied:
Building t al rint e) - ig ature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
95 Wilfin Road South Yarmouth,MA 34/3/// 250015006C
1.1a Is this an accepted street?yes x 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
44 173.43 365
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public N Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system N
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
John T and Mary P Barry south Yarmouth,MA 02664
Name(Print) City,State,ZIP
95 W M Road South Yarmouth,Ma 203-948-4556 maryitechtgmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building N Owner-Occupied N Repairs(s) 0 Alteration(s) N Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':
Remove old front door and replace with small window and wall. Remove existing inside entry door into living room and replace with wall.
Add walk in shower. Remove door and small wall into existing half bath add access from doset in bedroom to bathroom.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
.
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost3 Itx2 tt Tier x
3.Plumbing $ 2. Other Fees: $ C(V_`' 7
4.Mechanical (HVAC) $ List: II 3 S•00
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $8,000.00 0 Paid in Full 0 Outstanding Balance Due:
Z rd ED cc of tti.4.... J s ho1 -e r al--ct-e-'
12.,2iin1 D o _ - rr r
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
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 gnature) 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.
\O L V, & rr �
Print Owners or Authorize Agent's Namk(Elec m Signature) Date
N S:
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.) a,O o. (including garage,finished basement/attics,deck or porch)
Gross living area(sq.ft.) aka` Habitable room count 15 VCOYIC,INter
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system O'F Number of decks/porches /
Type of cooling system Enclosed Open 1/
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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'-� The Commonwealth of Massachusetts
l Department oflndustrialAccidents
='eii% 1 Congress Street,Suite 100
_lr= Boston,MA 02119-2017
. t
`� 4. `ems www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TUE PERMITTING AUTHORITY.
A Bent Information Please Print Leoibly
Name (Business/Organization/lndividual):_
Address:
City/State/Zip: \6 Phone#: 9}'� k
Are you an employer?Check the appropriate box: Type of project (required): '
L❑I am a employer with employees(full and/or pan-time).' 7. 0 w construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling ••
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
3.❑ am a homeowner doing all work myself.[No workers'comp.insurance required.]1
10 ��iuilding addition `
4. I am a homeowner end wilt be hiring contractors to conduct all work on my property. I will -
ensure that ail contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑P).utllbing repairs or additions t. . -.
5.0 t am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.tr--i&oof repairs
These sub-contractors have employees and have workers'comp.insurance.t '1
5.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14. -Other �► _l
152,11(4),and we have no employees.(No workers'comp.insurance required.)
'Any applicant Cult checks box MI must also fill out the section below showing their workers'compensation policy information.
1 Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConrractors 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. lithe sub-contractors have employees,they must provide their workers'comp.policy number.
1 an an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site
information.
insurance Company Name:
Policy's 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to 31,500.00
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 tndet the pains and pe74lisofper.iurytp-ftt)te i tformation provided above is true and correct.
I 4 r
Sisnat re: As / „ / f ate:
1-441.
Phone::::
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
1 6.Other_
Contact Person: Phone#:
TOWN OF YARMOUTH
g YAK Office of the Building Commissioner
4
=4a`� 1146 Route 28, South Yarmouth, MA 02664
°` :� l 508-398-2231 ext. 1260 Fax 508-398-0836
'''' �✓RAONASEO
HOMEOWNER LICENSE EXEMPTION
DATE:
JOB LOCATION: '1 `o: Icn Rd & a r Yw o /
„_ N STREET AD RESj� S CTIO O OWN �(j�"
HOMEOWNER JI�(Nh,d 1 q5W t` I I2 �V ,4/(c�
NAME -L 4 HOME PHONE WORK PH E
PI rt.. a ,
PRESENT MAILIN ADDRESS �1 c W t I
S—A,Ot(
ket o. ..Ge6,(_(
CITY O WN 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
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
- -Ya,, TOWN OF YARMOUTH
Office of the Building Commissioner
'
°—".` 41 1146 Route 28, South Yarmouth, MA 02664
wsfarM a
�``y °°_nE °3-j 508-398-2231 ext. 1260 Fax 508-398-0836
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` ''W debris resulting from the proposed work/demolition to bee.Q
conducted at. 9 1 cl rt. fins4fft_ Fo--01-4_ �S 6/
Work Address
Is to be disposed of at the following location: "1"""jtet— .
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, §150A.
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gnature Ap icant Date
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C9109/2022
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