HomeMy WebLinkAboutBLDR-25-51 - applicationONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Departm€nt
I 146 Route 28. South Yarmouth. MA 02664-4492
508-39tt-2231 ext. l26l Fax 508-398-0836
Massachusetts State Building Code. 780 CMR
Building Parntit .4pl ictrtittt To C'onstt-uct, Rcpqir, Rerun'ate Or Denu ish
u (hte- rr Twt-l'anily Dvelling
Y4
This Section For OIIicial Use
Buildinu Permit Number:Date Applied:
Building Olficial (Print Name)Signarure Dale
SECTION l: SITE INFoRMATION
l.t Pr(,t-d,\d re\!p n
o 11.,,)
Lla Is this an ac tcd strcet'l ycs
1.2 Assessors llap & Parcel Numbers
Map Numbcr
1.3 Zoning Iflformation:
Zoning District Proposed Use
1.4 Propertl' Dimensions:
Lot Arcr (sq ft)Fron (
1.5 Building Setbrcks (ft)
Front Yard Sidc Yards ENT
D
Requircd Providcd R!'quired Pror ided Required
1.6 Water Supply: (M.G.L c.,10. g5t)
Pnblic{ Pri\are E Chcck il'sE
1.7 Flood Zone Information:Zonc: Outside Flood Zone'l
1.8 Seuage Disposal Sl-stemi ?
\,lunicipal E On sire disposal sysrinr
SECTION 2: PROPERTY O1VNERSHIP'
Y o €vt, o ,.r< u mn
Citv. Stare. ZIP
A€- 5ot^z
No. aDd Streer Telephone
\amc (Print)
2.1 rof Record:
Email Addrcss
\lq b
SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Conslruction E Existing Building tr Owncr-Occupicd Rcpairs(s) tr Alteration(s) tr Addition D
Demolition tr Accessorv Bldp. E Number of Units Othcr ElSpccif)
ZE?.A
€L \-.t tlz D <, {-Bricf Dcscriprion of Proposed Workr Diz *r'z\
SECTION 4: ESTIMATED CONSTRUCTTON COSTS
Itcnr Estimated Costs:
Labor and Materials OIficial Use Onll-
l. Building S
l. Electrical s
3. Plurnbing t/z 4ortS
.1. Mechanical (HVAC)S
rcsslorlSu
5. Mechanical (Fire
s
6. Total Project Cost:S c)
tr Standard Ciry/Town Application Fee
tr Total Projecr Cosrr (hem 6) x mutiplier _ x
Check No. _Check Amount: _Cash Amount:
Total All Fees: S
l. Building Permit Fee: $_Indicate how fee is determined:
E Outstanding Balance Due:tr Paid in Full
2. Other Fees: S
List:
Only
Parcel Number
REGEIVI
FFlr a (t aaaa lrt-lJ,l.vtgcg
l"it
SECTION 5: CONSTRUCTION SERvtCES
(i.-/,c
Expifation DatcLicense Number
List CSL Type (sec below)
Description
L to 15.000cu. ft.)Unrestricted Build
R Rcstricted I&2 Fami Drell\t Mason
R('Rootin Cot
\\,S \\ indow and Sidin
SF Solid Fuel Buming Applianccs
I lnsularioD
5.1 Construction Superl'isor License (CSL)
,68-rcz-14q
,t tl z/t2
No. and Strcet
Tc'l Emarl addresshonc
I rtts I <.a,r
dr7OtZzrl
Namc ofCSL llolder
eoEtLz. rJ {-l-
at-
I)
5.2 Registered Home lmprovement Contractor (HIC)
HIC Companv Namt'or IllC Regisrranr Namc
Tel
I
AzD r21r7.. .< -Hau,z.u.Q-^,
ci ZIPTorr n State
No- and Strecto€t
c/tt1;t6
fxpir.rtlon Dirrc
D t *t tt,".r,z Zl e ,yt > t,t .z
Enrrtladdrcsi
La d21o9
HIC Rcgislratlon Number
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.c.L, c. 152. S 25C(6))
Workers Compensation Insurance allidavit must be completed and submitted with this application
this aflldavit will rcsult in the denial ofthe Issuance ofthc building permit.
Failure to provide
AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
SECTION 7a: OWNIR
I, as Owner ofthe subject property, hereby authorize_
to act on my behalf, in all mafters relative to work authorized by this building permit application.
Print O\r'ner's Name (Elecrronic Signature)Dutr'
SECTION 7b; OWNERI OR AUTHORIZED ACENT DECLARATI ON
By entcring my name bclow, I hereby attest undcr the pains and penalties ofperjury that all ofthe informarion
contained in this application is truc and accurate to the best ofmy knowledge and understandi
Print Owner's or Authorized ASent's Name (Electronic Signature)
n,-ng
"l//{"r/rr.-rz*
NOTIiS:
er important information on thc HIC program can be found al
l. An Owner who obtains a building pcrmit to do his,/her own work. or an owner who hires an unregistercd contracto(not registered in thc Homc Improvement Contractor (HIC) Program). t!.ill ,rol have acccss to thc arbitrationprogram or guaranty fund under M.6.L. c. 142A. Oth
N n rr .nrass. r.lor oca Information on the Construction Supervisor Licensc can bc lound at wrr rr _nlass.qold DS
(including garage, finished basement/attics. decks or porch)
Habitable room count ,
t)a{ Ltr'rches
o
Numbcr ofdccks/ po
2. \\'hen substantial work is planned. provide the information bclow
Nunrbcr ofbathrooms
Number offireplaces
Encloscd
Total floor area (sq. ft.)
Gross living area (sq. ft
Typc ofhcating system
Type ofcooling systenr
Number ofhalfbaths J
Number ofbedrooms <)
"Total Project Squarc Footagc'nray be subsrituted for ..Total-,]Projcct Cost"
At'Yl
0t1q7a
Type
?afr., ".- rr ?"aa, rat a eulf( idrTown. Srare. ZIP '
Demolition
Signcd Affidar it Anached? Yes.........No ........-
,a" (*_
Ooen
The Commonweahh of Massach usetts
Department of I n d ustrial Accide nts
Offtce of I n vestigat io ns
Lafayette Cit-y Center
2 Avenue de Lafayette, Boston, LL4 021I l-1750
www.moss.gov/dia
:
Namg ( Business,Orcan izarionllndi\ idual):Q)e.,^t4LD /Jozrr r-lZ t Dz /7
Address:2a E, L-z- ,J €a-
Ci StatelZi n1 r1 oJa75
Phone #:'ry- 7e2-Gq</
*Any applicant thal chccks box #l must also fill out the scction bclow showing thcir workcrs compcnsation policy information.t Homcormcrs who submit this alfidavil indicaling Ihcy arc dorng all work anl thcn hire outsidc conhctors must submit a ncw aflidavit indicating such:Conlmclors lhat chcck this box must allachcd an additional shcct showing thc name ofthe sub-contmclors and statc whctheror nol thosc cntities havccmployccs. If thc sub-con tractors havc cmployccs, rhcy must provide thcir workers. comp. pol icy n umbcr.
l.! I am a employer with
-
4. n
grnployees ( full andor pan-rime).*
2.Wt am a sole proprietor oi panner-
ship and have no employees
working lor me in any capacity.
[No workers' comp. insurance
required.l
I am a homeowner doing all work
mysell [No workers' comp.
insurance required.] i
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.l
! We are a corporation and its
olficers have exercised their
right of exemption per MGL
c. 152, S I (4), and we have no
employees. [No workers'
comp. insurance required.]
Are you an ";pl"ye.7ah""h1he appropriate bor:
3E
Tvpe of project (required)
New construction
Remodeling
Demolition
Building addition
Electrical repairs or additions
I l.E Plumbing repairs or additions
I2.I Roof repairs
t t.j o ther 1fi _p521aga21'-
6.
7.
8.
9.
l0
lam
inlor
Insurance Company Name
Policy # or Self-ins. Lic. #
Job Site Address:
un emPlo.let lhul is provitling wor*ers' compensation insurance for m; emplol,ees. Below is lhe polic-y and joh sitemoli0n.
Expiration Date
Attach a copy of the workers' compensation policJ- declaration page (showing the policy number and expiration date).Failure to secure coverage as required under Section 25A ofMGL c. 152 can leal to thi imposition of criminal penalties ofafine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the lorm ofa StOp wonf ORDER and a fineofup to 5250.00 a day against the violator. Be advised that a copy ofthis staiement may be forwarded to the gffice oflnvestigations of the DIA for insurance coverage verification.
I do hereb-t certif),er tlte pains a le Ities of perttlt' that the inlomothn provitled above is true and correct.
Si II c te /o
Phone #lo1,.7 / -/,4141 -u/r/,u -3 742 ,___-
Officittl use onl.1,, Do nol wrile in this areo, to he completetl b! ci4. ot toten officia!.
City or Town: permit/License #
Issuing Authorin (check one ):
lE]aoaruorHeattrr zn nuliaing o€partment 3Ecit.,.',"ro,nn clerk 4.E Eleorical Inspector SDlumbingInspector 6.EOther
Phonc #:Contact Person:
Workers' Compensation Insurance Affidavit: Builders/Contractors/E lectricians/Plumbcrs
Applicant Information Please Print Lesiblv
City/State/Zip:...-.---
)
d,J
TOWN OF YARNIOUTH
Office of the Building Commissioner
I I46 Route 28, South Yarmouth, MA 02664
508-398-223I ext. 1260 Fax 508-398-0836
Pursuant to M.G.L. c.40 954 and 780 CMR Section 105.3. I #4.
I hereby certi! that the debris resulting from the proposed worVdemolition to be
conducted at. I
Work A ss
Is to bedisposed of at the following location:tpol(,t
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter I t l, S t50A.
t*z 2 1O
Signature of Applicant
Permit No.
DEMOLITTON DEBRIS DISPOSAL APPLTCATION
Date
t
Licensee Details
Dc Informlrtion
me:
Name:J rider
Licensl. Ad&ess tnformation
License lnformation
MA
02675
Unitad States
cense No:
ue Date:
Status.
rng
dary License Type:
Business As:
License ype
Building Licenses5l't2t2010
Actave
License Renewal
4
Date of Last Renewal
Expiration Date:Today's Date:
a
4110t2024
5t1U2026
5r912024
u
No Pre site lnformatioa
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Undersecretary
N
noNALD J. HARKENRIdER
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Port
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