HomeMy WebLinkAboutBLDR-25-380 application 1V " 2
ONE & TWO FAMILY ONLY- BUILDING PERMIT
SEP 0 3 2025 € Town of Yarmouth Building Department . ° .Y A-
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I i 1146 Route 28, South Yarmouth, MA 02664-4492
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BUILDING DEPARTMENT 1 508-398-2231 ext. 1261 Fax 508-398-0836 , - ;�
--- I Massachusetts State Building Code, 780 CMR ' "
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Building Permit Application To Construct, Repair, Renovate Or Demolish 'tiro TTy`.¢tib,'q
a One-or Two-Family Dwelling RPOR" 0
This Section For Official Use Only
Building Permit Number: 1`i c) -�•_; - ..n :a Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 PPro eQ rty Address: 1.2 assessors Map&Parcel Numbers
1.1a Is this an accepted street?yesVr. no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: '. - k-
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
30 s yS {8'L !L$19 10 4
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 0 Check if ves❑ Municipal 0 On site disposal system ;12'
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
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Name(Print){ City,State,'ZIP
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No. and Street 1 elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other IU'Specify:read- dec. (P-0
Brief Description of Proposed Work': gAit I d J 0. A..e_c 1C i n 4-e \jat k
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 6 coo 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: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $
6. Total Project Cost: $ Check No. Check Amount: Cash Amount:
oo 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 / 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
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.
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Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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.) 6,1 000 (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"
TOWN OF O UT .
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g -iN� Officeof uil in Ss r
1146 Route 28, South Yarmouth, MA 02664
° 508-398-2231 ext. 1260 Fax �. 3
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HOMEOWNER LICENSE EXEMPTION
DATE:
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
HOMEOWNER
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATE ZIP CODE
Defmition of Homeowner:
Person(s)who owns aparcel ofland 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 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 11 0.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
TOWN OF YARMOUTH
/40e",
Office of the Building Commissioner
1146 6 Route 28,, South Yarmouth, MA 02664
PORAIt:, ^^ - 2 1. 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. 0' .a'C'eS Z encuk- ►. /IAA-, 6' .0 7 3
Work Address
Is to be disposed ofat the following location:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, §150A.
UtI(0 -(d-c)
Signature of Applicant Date
Permit No.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
S11114 Lafayette City Center
or
T lag t 2 Avenue de Lafayette, Boston,MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): AS'Al\n
Address: 5 ,,Ice r �cti� t �3 QS-� ,„ou+In/
City/State/Zip:Wesk `a -v►�ov}t-, (M O C 73 Phone #: C72q) — IS
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 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
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ElRemodeling
ship and have no employees These sub-contractors have 8. ElDemolition
workingfor me in anycapacity. employees and have workers'
P ty. 9. ❑Building addition
[No workers' comp. insurance comp. insurance.$
,_ rluired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.Lv"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 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.5Other dGe4
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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 perjuly that the information provided above is true and correct.
l
Signature: � Date:C 1 )-
Phone#: ( 77t( V I I S
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 3❑City/Town Clerk 4.0 Electrical Inspector S0Plumbing
Inspector 6.0Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center, 2 Avenue de Lafayette
Boston, MA 02111-1750
Tel. (617)727-4900 or 1-877-MASSAFE
Fax (617) 727-7749
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