HomeMy WebLinkAboutBLDR-24-471 applicaiton ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department p'g Y'4
1146 Route 28, South Yarmouth,MA 02664-4492 �� p
508-398-2231 ext. 1261 Fax 508-398-0836 :1
Massachusetts State Building Code, 780 CMR se,O _ H
4,
Building Permit Application To Construct, Repair, Renovate Or Demolish -4"c
ORPORAT SO Nbr°
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: (3t-k-2-y—(111 Date Applied: /2
:ill �/ 27
Building Official nt Name) Si ature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers _
1.1 a Is this an accepted street?yes< no Map Number Parc.,l u erC
1.3 Zoning Information: 1.4 Property Dimensions: SEP 13 2024
Zoning District Proposed Use Lot Area(sq ft) Fron'age ft)
1.5 Building Setbacks(ft) Buit DING Dr_NaK nntNr
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 )81
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owner'of Recor :
6 (S tt,Ljaa rc(t�cr�c /�?iJty //`C-P '�J, )ll./t/rKOce�c_�c / ) ? o,. ( 6 q-
Name(Print),DOU 0 IQ J K Nr2 i 7 Cy CocdrYW City,State,ZIP
6 (S rt��/ a.ra 1un 7 y<3— /2i� /1/SSC %b!r✓o W `�a no eC°dt
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied illI Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description o Proposed Work':
{1 Zr Ca4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ '0 o ' - 1. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ C3j4I t0 — 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ c 5o2 - List: 3,5-,06 e ( -02 q 7g-
5.Mechanical (Fire
Suppression) $ Total All Fees:$
7� _ Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 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 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 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.
I' , 5/JOB
Print Own 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
�swva.mas .aov oca Information on the Construction Supervisor License can be found at v\, .m,,iss. iov-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
Office of Investigations
/ Lafayette City Center
II
2 Avenue de Lafayette, Boston,MA 02111-1750
(.( .
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): y` X(- )CIi1e/Zr/! '
Address: 6 /l -..__
City/State/Zip:( 5 "\1 44f ` Q,A 6 4 V Phone#: Z 7 'I/ 3 `/Y/f
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 0 I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. ❑Remodeling
2.I: I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. 0 Demolition
workingfor me in anycapacity. employees and have workers'
p tY Y 9. 0 Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.jR.,I am a homeowner doing all work officers have exercised their 11.11 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0Other
_ 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.
: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 herey certify under the pains and penalties of perjury that the information provided above is true and correct.
�f/�
Signah�fe--?""/ / tom/` Date: / 3 a 10..i' c ®� a
4:��% [
Phone#: c ,..J / /3 11' 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(check one):
1DBoard of Health 20 Building Department 3:City/Town Clerk 4.3 Electrical Inspector 51klumbing
Inspector 6.DOther
Contact Person: Phone#:
TOWN OF YARMOUTH
^ o.,g Office of the Building Commissioner
= �
o', 1146 Route 28, South Yarmouth, MA 02664
' 508-398-2231 ext. 1260 Fax 508-398-0836
cMe s y
`�APORAS�f`\
HOMEOWNER LICENSE EXEMPTION
DATE:
JOB LOCATION: 6 /? / S' DOS 6'
jNAME / S BEET ADDRESS SECTION OF TOWN
HOMEOWNER 4 ICJ ' Z57 f/3' 1 27Y
HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS ./
CITY OR TOWN STATE ZIP CODE
Defmition of Homeowner:
Person(s) who owns aparcel 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 11 0.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 SIGNATURES'/ I zCj
Y9' TOWN OF YARMOUTH
fg r*
Office of the Building Commissioner
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 /pj
Work Address
Is to be disposed of at the following location:
IMV/69/14.,
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, §150A.
1.3 :4e"c.• •°? X
Signatu of Applicant Date
Permit No.
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