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Home My WebLink AboutBLDR-24-540 applicaiton ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth, MA 02664-4492 r-'• , 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 ed„ CHEESE �R PQR AT E� a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: 61-.b -may- 5 ) Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 lgpertinesst sr 1.2'ngsers Map&Parcel Nu i b-glrss 1.la Is this an accepted street?yes x no Map Number Parcel Number 1.3 onin Information: 1.4 Prrolfrty Dimensions: ' ` 5 Zo ing District Proposed Use Lot Area(sq ft) •' Frontage(ft) 1.5 Building Setbacks(ft) RECEIVED Front Yard Side Yards Rear Yard Required Provided Required Provided Required OUT 2 Rawl 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 spo S stem RTMENT PP Y� Sewage P Y___ Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ � SECTION 2: PROPERTY OWNERSHIP' j�/� 2.1 Owner1ARecord:ALA'&14 VfiAIP100 rf /"l."J 15 Dad l 5 Name(Print) y,State,Z fl�] 1 No. and Street +Telep one Email Address SECTION 3: DESCRIPTION OF PROPOSED WORD(check all that apply) New Construction 0 Existing Building Ql,, Owner-Occupied Repairs(s) Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: / Brief Description of Proposed Wor z. WtginACE r ) )l w SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1 3. 000 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ VV ❑Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: (D 0.0 D .it-4 W57 5. Mechanical (Fire $ Suppression) Total All Fees: $ 6. Total Project Cost: $ at, DD Check No. Check Amount: Cash Amount: ❑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) Type Description No.and Street 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 61;(14Y1n / )401411f5 to act on my behalf,in all matters relative to work authorized by this building permit application. TiA4 �fl. in - 18ex�/ Print Owner's Name ectronic Signatur8) 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 's application is true and accurate to the best of my knowledge and understanding. aigG oz / 04-034- Print Owner's or Au orize Agent's Name lectronic Signature)� gn ) 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 Information on the Construction Supervisor License can be found at 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 Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �j Please Print Legibly tJ Name (Business/Organization/Individual) 0f105 D kne✓ _ Address: 2'lj C I / ' oT 1 City/State/Zip: ,�'+iIJ1I95 Phone#: (7/4 a?�/ 4 7 45# Are you an employ ? Check the appropriate box: Type of project(required): 1.El I am a employer with 4. 0 I am a general contractor and I have hired the sub-contractors employees (full and/or part-time).* 6. El New construction listed on the attached sheet. 7. ElRemodeling 2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' P ty. 9. ❑Building addition [No workers' comp. insurance comp. insurance.* e uired. 5. ❑ We are a corporation and its 10.0Electrical repairs or additions q ] officers have exercised their 11.0Plumbingrepairs or additions 3. I am a homeowner doing all work P myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] ' c. 152, §1(4),and we have no employees. [No workers' 13.El Other comp. insurance required.] *Any applicant that checks box#I 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 hereb ce p; under the ins d nalties of perjury that the information provided above is true and correct Signature: ' i 4 Date:/ # /S 'gdfs Phone#: 74'e? alp - 0416 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 3ElCity/Town Clerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.0Other Contact Person: Phone#: ° HOMEOWNER LICENSE EXEMPTION DATE: /t' - 1t3 ' *' JOB LOCATION: _6#1 EWi ✓ VI polo ,GSREE ADDRESS E6Q` o, . Y �24 70 ��ION 0 HOMEOWNER NAME HOME PHONE WORK PHONE P SENT M ILING ADDRESS 3‘/ CiJ1 T 7o gionu ridgy ftln (�e�� 76 CITY OR TOWN STATE ZIP CODE Definition of Homeowner: Person(s)who owns aparcel of landon 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/or farm 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 gf780 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 tite4.4_ c i' / I of 1r4At. MATTA c" 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 res lting from the proposed work/demolition to be conducted at. Z17 Cii7 TI Work Address Is to be disposed of at the following location: AC/ be (5i�_l' Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. 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