HomeMy WebLinkAboutBLDR-25-204- R E C E I V i& TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department jpo YAK
MAY 20 2025 1 146 Route 28, South Yarmouth, MA 02664-4492 /Z 'p
508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT Massachusetts State Building Code, 780 CMR AT ACM«ISE 3`
By: Building Permit Application To Construct, Repair, Renovate Or Demolish '',, 4,, ,,%
b
ORPORAT O,e4
a One-or Two-Family Dwelling �`�- E
This Section For Official Use Only
Building Permit Number: azig..„),5..,: ii,t Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
75 Pc 324_4 -J 6'A+C1 t Lit44-)/
1.1a Is this an accepted street?yes ndd Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Ii) 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:
Zone: Outside Flood Zone?
Public 0 Private 0 Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ��^^
Dt63, \-k ei 1 W ` ),^c►+ k-,f}/i N)a rr� }iiia.
Name(Print) City,State,
2.5 '�L 1�6= 11-Li r4/ 5 - 77,2-1 Z a' 1�\-� l t-.�r e v P(4/-S ,�
No.and Street / Telephone Email Address 14 a-I
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s)g Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:'2 F IL,t/!-L air- °"Z A LJ, t 1`,,,..) l4,,,,,2d.,a C ►--
`) friar ,e -I may L61.icew W I g 0 S -Pr_ r=l.t
"�n v'gt- /1.--i- 1 td,�.%o v3 ,)-- Ct `c2,,s er- /4/ ' C -(1:i-Iw 1 4 0 L. = .- (-r‹.- h•S to Lic ii. .,D
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ V3/
0�t 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ 0 Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ a.---
4.Mechanical (IIVAC) $ -------- List:
5. Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ t -) 0 Paid in Full 0 Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
OB001 D ) S"e er I —etc— ZO 2(
C S
icense Number Expiration Date
Name of CSL Holder
r� List CSL Type(see below)
a4-4.tZe&-f 1 r111 a ]. _. T e Description
No.and Street
I -' �J U Unrestricted(Buildings up to 35,000 Cu. ft.)
/
6-f W I TZ vk"Li U c)0 / - R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
•
S_ J i z. RC Roofing Covering
✓�/1��v 1'� WS Window and Siding
SF Solid Fuel Burning Appliances
_UQ 3‘7 --574v evroL1LS. IiN1)L1-- I Insulation
Telephone Coq E re r.fl 4.)L/ D Demolition
5.2 Registered Home Improvement Contractor(HIC) 4 14-4 _ M g 4 e "'*"M Registrar Number Expiration Date
HI Company Name or HIC Re=istrant Name
cti-IW-
No.and Street Email address
/.56 I.JI i c1fvG�0 to.. S y 4 Soi.--347>'1Zo
City/Town,State,ZIP PSI,A.. G261G`f 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 0 (}(L/eS �i/4 e L/
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner s Name(Electronic Signature) Date
„0,y._
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.
jersorizedcnt': clectronic Signature) Date
i_.
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
w w w.mass.lzov,oca Information on the Construction Supervisor License can he found at www.mass.govidps
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"
O� YA�
TOWN OF YARMOUTH
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. 23 O''"- ( /41-1z-t/O
Work Address
Is to bedisposed of at the following location: \ -
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, §150A.
Viz_ 16)
gnature of i nt Date
Permit No.
^-^z_` I he Commonwealth of Massachusetts
r Department of Industrial Accidents
y Office of Investigations
(4r , _.4 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 Please Print Legibly
Name (Business/Organization/Individual)C40.tA—/Le,e ./ 7/1G<<__. _
Address: 15( pi ''T—e,1%%--VJ6c ' D
City/State/Zip:5. 4 it)Oa 11-- 141/. _ Phone#: j e —36 -7-5 72
Are you an employer. Check the appropriate box:
Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.71.1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.{
required.] 5. ElWe are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] ' c. 152,§1(4),and we have no
employees. [No workers' /13 OthcPC -�''
comp. insurance required.] W/(„- , LIS rn—
*Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc 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: - t'Li (/- 1,Ji4-- City/State/Zip. t— 14"
Attach a copy of the workers' compensation policy declaration age(showing the policy nu er 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 S 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 th IA for insurance coverage verification.
I do hereby c 'y un a ie pau. enalties o perj at the information provided above is true and correct.
Signatur . �— - Date: C _IL— 7 dL '''
Phone#: — ` _ -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):
1❑Board of Health 20 Building Department 30City/Town Clerk 4.1:Electrical Inspector 5alumbing
Inspector 6.0Other
Contact Person: Phone#:
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Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Re ulations and Standards
Cons n isor
CS-080901 ires: 01/25/2026
CHARLES Ep'IMMONS
156 WITCH OD RD
SOUTH YAR( pUTH MA 02664 0
O Ot.LVdi100
Commissioner QGI,..Lz:.•4--
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Reaistration Expiration
180664 12/10/2026
CHARLES SIMMONS
CHARLES E.SIMMONS
156 WITCHWOOD RD
SOUTH YARMOUTH,MA 02664
Undersecretary
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