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HomeMy WebLinkAboutBLDR-25-281 applicaiton RECEIVE ® JUL 0 8 2022NE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department BUILDING DEPARTMENT 1146 Route 28, South Yarmouth,MA 02664-4492 BY 508-398-2231 ext. 1261 Fax 508-398-0836 0. , krt.y Massachusetts State Building Code,780 CMR _SA Building Permit Application To Construct, Repair, Renovate Or Demolish s -ti, "` "',„4. OTRf'ORATED a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 8Lb?- s--d,c f Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers erx,/ 1.1 a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 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: Zone: Outside Flood Zone? Public Private❑ Check if yes Municipal 0 On site disposal system Er SECTION 2: PROPERTY OWNERSHIP' 2.1 ner'of Record: -3°7 D �_c"- ll y (/€5"f y, , ,7,4 o i&73 Name(Print) City,State,ZIP ,v7C yilv�, ?7fr et-' MY/ q (Ad uw411kcLiy")aa(12-644 /L. Cam No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORD(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 1 Addition 0 Demolition I Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': ,fie kcw A 'c& t/v�l� SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 3 yp�, -- I. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ �/� CI Standard City/Town Application Fee 0 Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 41/4 2. Other Fees: $ 4.Mechanical (HVAC) $ A/A List: 5.Mechanical (Fire $ , ra Total All Fees:$ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 3'00 / ❑Paid in Full 0 Outstanding Balance Due: ,; SOS 30 JUL • - .1 •rwt: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) C,S �,0533�c � �? �� ` ' 74‘,-/ l /741ie-C-C2 License Number Expiration Date Name of CSL Holder Lij 74, C71 List CSL Type (see below) No. and Street Type Description U)t5 d Unrestricted (Buildings up to 35,000 Cu. ft.) Ae-,70P �/ ©a R Restricted 1&2 Family Dwelling City/Town, State, ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances `ó2$ ' lei ire° I Insulation Email address -© D Telephone .� _ _ Demolition 5.2 Registered Home Improvement Contractor (HIC) //A/4/i: /0470).0013 HIC Registration Number Expiration Date g P HIC Company Name o HIC Re istrant Name 4,4/iwatio.,,A4.-- 1•7de INV -C-"7 No. and Street 6� Email ad ess Ltei, Yo9,4000e., #4,4 c4-. 5F--,29V- gY fic 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 . 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACT I R F 1 R DING PERMIT I, as Owner of the subject property, hereby authorize to act on my behalf, in all matters relative to work authorized . /this building perm' application. • /Ai (--L4 "7214 .. RiEL L 7//1zc 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. Print Owner'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 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" The Commonwealth of Massachusetts Department of Industrial Accidents �� --a' Office of Investigations Lafayette City Center / 2 Avenue de Lafayette, Boston,MA 02111-1750 Y www.tnass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information y� Please Print Leeibly Name (Business/Organization/Individual): ft /� // /tip Address: z7 Geiii/% 7-Zes, CI- City/State/Zip: Lt).'s94- /0✓.14, /114 o &73 Phone#: r 2-) %-l9)g-t/ Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction listed on the attached sheet. 7. C rkemodeling 2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp.insurance omp.insurance.$ required.] 5. [(We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. t _ Date: 7 1/4""�o) s` Phone#: :CV --,)?Y`�v.) '`)t 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 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: �g Y TOWN OF YARMOUTH 3 °� Office of the Building Commissioner "0 1146 Route 28, South Yarmouth, MA 02664 9.QRPO RATE��bA° 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. ` /4 1 7 ✓r v74 Work Address Is to be disposed ofat the following location: y4n. 494 A/4-3 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. 24-/.,10..› Signature of Applicant Date Permit No. f Massachusetts .'' i FORM a „-- � � `�� Commonwealth o - . E: Department of Industrial Accidents 7n1 Office of Investigations - Dept, 153 MAY 2 . ; 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 . . ,.____ . ._ . # http://www.mass.gov/dia y inv 'o •AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS Chapter 169 of the Acts of 2002 amended M G.L. c. 152, §1 (4) by adding the following paragraph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation. Notwithstanding section 46, these provisions shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set forth in section 2 5 C." Pursuant to M.G.L. c. 152, § 1(4) as amended, I/We the undersigned officers of: DeMarco Contracting, Inc., 361 Hudson Road, Sudbury, MA 01776 - -` (Name of Corporation and Address) each holding at least 25% of the issued and outstanding stock in said corporation, do hereby invoke the right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s) or director(s). I/We the undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further, I/we the undersigned do understand that, should the above-named corporation hire or have in its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said corporation is required to obtain workers' compensation coverage for the employee(s) as prescribed by M.G.L. c. 152, §25A. I/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checked the appropriate box below my/our name(s) indicating my/our desire to be exempt or not to be exempt from the provisions of M.G.L. c. 152. Signed under the pains and penalties of perjury: - Paul _ 04/29/2021 Signature Print Name & Title Date (mm/dd/yyyy) r • I wish to exercise my right of exemption or El I wish NOT to exercise my right of exemption Signature Print Name & Title Date (mm/dd/yyyy) flI wish to exercise my right of exemption or Iii wish NOT to exercise my right of exemption Signature Print Name & Title Date (mm/dd/y; y) I wish to exercise my right of exemption or fl I wish NOT to exercise my right of exemption Signature Print Name & Title Date (mm/dd/yyyy) Li I wish to exercise my right of exemption or n I wish NOT to exercise my right of exemption Note: ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES_ Instructions on back. Form 153 -- 7/2010 .3N 9- ,;-.2, .1.01;14v --Vt'' 1-pi aj4l I rs fir `. di'd e d--1' gni - ! , 4-49A d rchi(V -7-yvcc, s4474 5-1 THE COMMONWEALTH OF MASSACHUSETTS Registration valid for individual use only before the Office of Consumer Affairs&Business Regulation expiration date. ff found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation TYPE Corporation 1000 Washington Street -Suite 710 Registration Expiratf°n Boston,MA 02118 114418 10/06/2025 DEMARCO CONTRACTING,INC. A 1 8 WINCHESTER COURT Not Valid without signatureWEST YARMOUTH,MA 02673 Undersecretary Commonwealth of Massachusetts u' Division of Occupational Licensure Board of Building Regulations and Standards Constuitilltbn cS rvisor CS-053325 ESpires: 08/22/2025 PAUL P DEMARCO r 8 WINCHESTER CT WEST YARMOUTH MA 02673 . r /'i L t'0.-'' Commissioner