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ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department of riic
1146 Route 28, South Yarmouth,MA 02664-4492
IleAi
508-398-2231 ext. 1261 Fax 508-398-0836 la
Massachusetts State Building Code, 780 CMR o.o,,
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 1 lk f --'_., Date Applied:
/ Z.,........./". 9- A i A Ell---nm 717-'-
Building t- coal(Print ., e) Alir ign, re ii Date
SECTIO 1:SI ' INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
22IV*Le aotoV 4.4.vG yq anti'
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/Oj?o0 /02
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 A
Check if yeiw
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Record:
woYOGAIWAINCIa QS'i+oE.! A .YAier.sivTtij rn.y aair4 7 3
Name(Print) City,State,ZIP
2Z osv&excvv V G.s.,,E 44.1 y4q z7d A3aQresoae&Ceer.0441‘7..7
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building:6 Owner-Occupied 'I Repairs(s) 0 Alteration(s) 70 Addition 0
Demolition 0 I Accessory Bldg. 0 Number of Units Other 0 Specify: RECEIVED
Brief Description of Proposed Work':
Rya .eoo.•, v- roJ4..ET11-sd06+.0 JUN 10 2074
SECTION 4: ESTIMATED CONSTRUCTION COSTS BUILDING DEPARTnnENT
Item Estimated Costs: Official Use OnlyRy
(Labor and Materials)
1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
0 Total Project Costta�k4916.)ix multiplier x
3.Plumbing $ 2. Other Fees: $ C 1u 2-g0 _
List: ��`iC �''
4.Mechanical (HVAC) S b 0
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ i 0 Paid in Full ❑Outstanding Balance Due:
Toros- -4-
le' >AIc46 3`,O
v o ? Pbsvnw
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 l&.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 I 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
I 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.
''Je 4P!4.,s' agrees a/4k _ G1i01 y
Print Owner's or Authorized Agent's Name (Electronic Signature) Date
y
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" ,3 1,/p ,,, *& r
The Commonwealth of Massachusetts
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Department of Industrial Accidetzts
1= 1 Congress Street, Suite 100
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BOStOfZ_� -� MA 02114-2017
IMMONIMIr
'q1M Nor"� • • www. tnass.gov/dia
Sr
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERiMITTIN'G AUTHORITY.
Applicant Information Please Print Legibl
NameY
(Business/Organization/Individual): y01,4i,= ,/Q
Address : 2 Z toy, v.-s-e o v►y L. ,•v,,,,�
City/State/Zip : A )4•00r .,00► 00 0.2L-7 hone #: G oa3 y9V ex 7
0
Are you an employer? Check the appropriate box: j
Type of project (required):
1 . I am a employer with employees (full and/or part-time).*
7. New construction
2. 7 I am a sole proprietor or partnership and have no employees working for me in
8 . !.� Remodeling
any capacity. [No workers' comp. insurance required.]
3. D I am a homeowner doing all work myself. [No workers' comp. insurance required.] r 9. Demolition
. q J
4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 n Building addition
ensure that all contractors either have workers' compensation insurance or are sole 1 1 . ' Electrical repairs or additions
proprietors with no employees. ;
12. N 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.: 1 Roof repairs
6.n We are a corporation and its officers have exercised their right of exemption per NIGL C.
I Other
152, § 1 (4), and we have no employees. [No workers' comp. insurance required.]
*Any applicant that checks box 41 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.
p y
Insurance Company Name:
Policy # or Self-ins. Lic. =: Expiration Date:
Job Site Address : City/State/Zip:
P
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 bya fine upto $ 150
and/or one-year imprisonment, as well ascivilform WORK , 0.00
P penalties in the o f a STOP ORDER and a fine of up to S250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insura
nce
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: •"F440.0<dienye----
Date: 4 a .Z1I
Phone #: 4.31 '14!471 10,Z70
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):
I . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
P
Contact Person : Phone #:
_ TOWN OF YARMOUTH
(ick(f
luitc;3 BUILDING DEPARTMENT
a ; % 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: 440.�244
JOB LOCA"FI0N: dGyr4ieo arenaiR .22 rvo vcscotir V Z. 14.•42. '7" )404 ripa to T-y p cu
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" oVAoid •o as•wsOde. 22 .+s vs age vy L-04.. 4" ,T- ) orAvo ry o z6�3
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS 'Do .QbIC 104$„5-
-%S :40 Y41.4-970&PY-.40 .",A oze.dc•y
CITY OR TOWN STA 1"E ZIP CODE
The current exemption for 'Homeowner' was extended to include owner — occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that such
homeowner shall act as supervisor. (State Building Code Section 110 R5. 1 .3. 1 )
Definition of Homeowner:
Person(s) who owns a parcel of land on which he / she resides or intends to reside, on which there is or is intended to
be, a one or two family attached or detached structure assessor_y to such use and / or farm structures. A person who
constructs more than one home in a two-year period shall not be considered a homeowner; such `homeowner" shall
submit to the building official, on a form acceptable to the building official, that he / she shall be responsible for all
such work perfoi u .ied under the building permit. (Section 110 R5. 1 .3. 1 )
The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE A:::::44"414+e—
APPROVAL OF BUILD LNG TG OH lCIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch. 142. Yes No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S LNS URANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this 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 certify that the debris resulting from the proposed work/demolition to be
conducted at
Work Address
Is to be disposed of at the following location :
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.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152. §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02 1 1 4-20 1 7
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 6I 7-727-7749
Revised 02-23-15 www.mass.gov/dia
,..,:;k-vi);;-• TOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant
Building Site Location- .12Z APO tol.SeSevle 4.4~0, 414,00.aro- Agodurmi..007-.4,4
4.
Proposed Improvement a AMP:4 OFT,Ors' ArtI4/40.-tik * 440.1r .0064e4404tares
do04.0010Wrie7"v 4fano 4Vtiolor.tory. isloar AP•Oost-b A.4.4.0 004 ANIF*Oano viwritirjr•
_ifiti•40141440,4* 720091411 1,40.4.6 41A0ALlifellnef40444. /04446,ira•riee... "AO dr"lot.
Applicant: 04411;010004.40) .00 . airovirodirsge Tel. No.: d" 41PilV 402 7 IP
Address: del 011041,411k4thite.,444.0 ..4241e.,"feir3 00t4111.0.4/v0dt 4•40•Aif Date File
d:—,L4L4 "
**ifyon would like e-mail notification of sign off.please provide e-mail address: dge aftee,, dolgotr: "War
Owner Name: -4344 410611101,42 iCr 41. ezetrionr"^0."41* aagrovii4C40
_-
Owner Address: degt .0.1444.40,40"044.as ActAt A44.1z4vivit MOwner Tel. No.: OdUr 4,441St 7it
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
:57,.2.11:-.1t7VED (1.) Site Plan showing existing buildings, water line location,
MAR 2 3 2023 and septic system location;
(2.) Floor plan labeling ALL rooms within building
HEALTH DEPT. (all existing and proposed)—
Note: Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY- DATE:
PLEASE NOTE
COMMENTS/CONDITIONS:
e,7}c
File number: 170705-2 UNREGISTERED LAND
Attorney: LAW OFFICE OF SEAN EAGAN Deed Book 26735 J j 262
Lender: CITIZENS BANK N.A. Plain Book 230 page 141 Lot(s) 60
Owner: JOHN MUCCI 2012 TRUST REGISTERED LAND
Reg. Book Sheet Toffs):
Date: 7/6/2017 Certificate of Title
Assessor's Map 49 Blk: Lot 205 1 Census Tract
MORTGAGE INSPECTION PLAN Scale: 1'=40' I
22 MUSCOVY LANE, WEST YARMOUTH, MA
LOT 1 LOT 51 LOT 52
102.00'
I SH..I LOT 60
10,200 SF
DK
N/F o
-
o LOT 59
STUDLEY 0 1 STY
#22
o`
102.00' '" TO CLEAR BROOK RD
U .� SC VY _ A \ �-
CERTIFICATION
I CERTIFY TO THE ABOVE ATTORNEY,BANK,ANI)THEIR TITLE INSURANCE COMPANY THAT THE MAIN BUILDING,FOUNDATION OR
DWELLING WAS IN COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN CONSTRUCTED(WITH RESPECTTO
STRUCTURAL SETBACK REQUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS.GENERAL
LAW TITLE VII,CHAPTER 40A,SECTION 7.
FLOOD DETERMINATION
BY SCALE,THE DWELLING SHOWN I IERE DOES NOT FALL.WITHIN A SPECIAL.FLOOD HAZARD ZONE AS DELINEATED ON A MAP OF COMMUNITY
#25001C05871 AS ZONE X DATED 7-16-14 BY THE NATIONAL FLOOD INSURANCE PROGRAM.
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SKETCH ADDENDUM He Ir 0029464226
Bernmertient Richard Carney
Property t'uddrest: 22 Muscovy Lane —.
CIty West Yarmouth County Barnstable State MA bidCour 02673
Lender Citizens Bank,N.A.
Sketch __
Sketch
r 1
1
I
I
1
I
Wood Deck
First Floor [Area: 400 ft2)
[Area: 1168 ft']
Family Room
21'
Bath I Dining
Bedroom Room t Room Kitchen
1 Car Attached
[Alt-,t. 2t: 1 PVJ CV
t C
tf V
t �•
Bedroom Living Room Screened Porch
lAt ea: 112 111 E ,
t•
48'
Bath j
Basement
[Area: 1180 ft2]
`y Family/Rec. Rom i WIC (Unfinished) ` �
Cn
34* '1
14"
et t!
Lonny Area k^
Feral r±At Arra Casco
Nraniax+n. Area 1 t li r4== First Root
rt
IGar.Na� eW tt .
x t.CO-1168 1t'
4eoaCra :$lt,= _ is r C • 19EifCs
4;'T,4 Ct' 'E65Eme�: P� . .a • en, tt,
1 . Y{ c :
;creerea l r$:h: !18 h
total Lnp Area(rrwruledt: t iw Rs m
116a ft'
4
Property Location 22 MUSCOVY LN Map ID 49/205/t/ Bldg Name State Use 1010
Vision ID 7428 Account# 7426 Bldg# 1 Sec# 1 of 1 Card# 1 e1 1 Print Date 8/13/2021
CONSTALTC7IONffETA1L CONSTAUCT161TbETATI.(CONTINUED)
Element Cd Desorption Element Cd Description
Style: 01 Ranch WDK
Model 01 Residential
Grade 03 Average
Stories. 1 1 Story
Occupancy 1 CONDO.ATA
Exterior Wan 1 25 Vinyl Siding Parcel Id ICI Owne 0.0 BAS 20
Exterior Wall 2 jB JS
Roof Structure. 03 Gable/Hip Adjust Type Code Description actor%
Roof Cover 03 Asph/F Gis/Cmp Condo Fir 12
Interior Wet 1 05 Drywall/Sheet Condo Unit
Interior Wall 2 C65T/MA KET VALUATION'
Interior Fir 1 12 Hardwood 13 20
Interior FIr 2 11 Ceram Clay Til Building Value New 318,831 48
Heat Fuel 03 Gas FOR
Heat Type: 05 Hot Water
AC Type: 03 Central Year Built 1976
Total Bedrooms 02 2 Bedrooms Effective Year Built 14
Total Bthrms: 2 Depreciation Code G
Total Half Baths 0 Remodel Rating
Year Remodeled
Rooms: Depreciation% 15
Total Fixtrs 24 BAS 22
Total Roo FBM 14
Bath Style: 02 Average Functional Obsol 0
Kitchen Style: 02 Average Ext Trend Factor Comment FSP
Condition 10 8
Condition%
Percent Good 85 14 12
RCNLD 271,000 34
Dep%Our
Dep Ovr Comment
Misc Imp Our
Misc Imp Ovr Comment
Cost to Cure Ovr
Cost to Cure Ovr Comment � �,, .r t r ,tr,n
OS-OUTBUILDING is YARD 7TEi6TS(CJ"73�F•BUILDING EXTRA FEATURES(B) tl .{j
Code Description L/B Units Unit Price Yr ICC Cond.Cd %Gd Grade Grade Adj Appr.Value ''' 1 a
FPL1 FIREPLACE 1 B 1 2200.00 2000 85 0.00
SHD1 SHED FRAME L 80 8.00 1976 90 0.00
EOS Errol Outs Slier B 1 0.00 2000 85 0.00 0 ° ' I t
BUILDING SUB-AREA-SUMMAKY SECTION t,...,'I f-r, 1,
Code Description Living Area Floor Area EH Area Unit Cost Undeprec Value � �� i •T'a�i#` '' '`
BAS First Floc 1,168 1,188 1,168 174.78 204,144 - . •" 'Wt 1
FBM Basement,Finished 0 1,012 455 78.58 79,525 - - .� _„
FGR Garage 0 264 106 70.18 18,527 '�`
FSP Porch,Screen,Finished 0 112 28 43.70 4,894 ,q ps
WDK Deck,Wood 0 400 40 17.48 6,991
Id Gross LIv nesaa Area 1,168 2,958 1,797 314,0151
a