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Home My WebLink AboutBLDR-24-437 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department Og Y` .4; 1146 Route 28, South Yarmouth, MA 02664-4492 Z p; 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish - +,o ATTAGHEEB.b�° f a One-or Two-Family Dwelling � APORAT � --' This Section For Official Use Only Building Permit Number: 6 1./7)R - ,1 L/_ 1439 Date Applied: Building Official(Print Name)/ gnature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1/3 I)In/ I.$ Dr 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ec'' Zoning District Proposed Use Lot Area(sq ft) FroitaE42 E1VE. D 1.5 Building Setbacks(ft) aa�� 9/, Front Yard Side Yards Rb'd�'i'gd' 2024 Required Provided Required Provided RegaiI(11ILDING DEFIARNti1 T Ejy. 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 Owner'of Record: Rd>B 1Zi I- 50 Ufa Y4e/yo111, Name(Print) City,State,ZIP ✓ 0 IY SELL/5 Opt'• 5°8-Z80-Z317 rdrbrl`32Id),greod No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s)X Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:_ W6 Wil/IE Tglm SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 200a.00 I. Building Permit Fee: $ Indicate how fee is determined: - ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 7.5 ,00 4. Mechanical (HVAC) $ List: 6m,k 5.Mechanical (Fire Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 2`/1".(j,hi) ❑ 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 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 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. Rai eg r ettf> )5i /Z11/262-1Print Owner s or Authorized Agent s Name (Electronic Signature) 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 IIMMIBB::t - 1 Congress Street, Suite 100 q==t•f= Boston, MA 02114-2017 ,m,.•°� 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): xo.gz r„j. 'LER ✓ Address: 43 Pji yiIi_5 4PL L/ City/State/Zip: A91J174 7,gemoo , jMI 6Z60Phone #: 63 200 —2 3/ 7 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. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in . anycapacity. 8. El Remodeling p ty.[No workers'comp. insurance required.] I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on property.mY I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑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 13.El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ID Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box#1 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. 1Contractors 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: B_ Date: a/40024 Phone#: 508.-- 260— 23/7 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 N OF YARMOUTH OUTH o A Office of the Building Commissioner ry� o 1146 Route 28, South Yarmouth, MA 02664 o vy 508-398-2231 ext. 1260 Fax 508-398-0836 �, N T#CNLtgf� HOMEOWNER LICENSE EXEMPTION DATE: 04/264 JOB LOCATION: 4000iW4L`5 P.R • /wI/! 4i47ouril NAME STREET ADDRESS SECTION OF TOWN HOMEOWNER . E,l?% gh'EP 58 - o --z3'7 NAME HOME PHONE WORK,,// PHONE PRESENT MAILING ADDRESS 43l/YLL/SQ,c J 5oV1 1 /�� 6Z66 L/ CITY OR 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 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 of 780 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 1(2, �/_ Y. ' � TOWN OF YARMOUTH Office of the Building Commissioner ht ' 1146 Route 28, South Yarmouth, MA 02664 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 debris resulting from the proposed work demolition to be conducted at. 43 �/�j�yLL`,� PA' . Work Address Is to bedisposed ofat the following location: 7 "AJ d ) øk'4'OtU2V 7Ex)ME -WA(TIC Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 1 l 1 , § 150A. adeeti_g° . 6./g4742,1 Signature of Applicant Date c.= Permit No. itti 3, 2:V, •e- .,,7. '4a `-ejy 'S +1�+9 A�!� .&^'1`1^�4� i .��MN10� 7NI to! ..-:;',-1-:- -,,-,,,..i.i,,,iil.--_ ;,,,,,,,,4;_:-,- ,- .. ::,..,,,,,...:, L...„..., ,..„..,,,,,_ , ,,, . •,,,,,„..,., -- `' "`- -;,..„.„. il.,...._,-,. .- • . .„,„_;...... ' 4r is rtc . , .-V r s,4±4* .,''' -N 4,e,/ f> _ r 1 ' i h _ �• i 56? 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