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Home My WebLink AboutBLDR-25-595 R E C E I V VW & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department O'4''rYA.jq` DEC 15 2025 1146 Route 28, South Yarmouth,MA 02664-4492 ;gyp, C1. 508-398-2231 ext. 1261 Fax 508-398-0836 �'�;' t i /` J Massachusetts State Building Code,780 CMR C H. BU I LD6 f9E�PI1TnI Permit Application To Construct, Repair, Renovate Or Demolish /ti�MA rACM[[3 Ni.�q t ' a One-or Two-Family Dwelling ARP°R"`E� This Section For Official Use Only Building Permit Number: 51. , 2 S- 57/S Date Applied: Building Official(Print Name) Signature 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 Parcel Number 1.3 Zonint'ormation: 1.4 Property Di ensions: 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: Public Private 0 Zone: Outside Flogd,Zone? Municipal 0 On site disposal system Check if yes SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Recor 5l D N2J 1-v� a'- y6� wdTA Name(Print) ity State,ZIP . .1 6l5 4 J ace 5vvi7 Y3a9 f9 k 14i k - No.and Street Telephone Ema ddress et f /..�lli SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Speci • Brief Descriptio of roposed or -: Ca/ -(l f ui 4 bcf2t(-J Hit k ,n& N 13PR -• fILJY SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ i S07 do. 1. Building Permit Fee:$35 Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ t jdOO 0 Paid in Full 0 Outstanding Balance Due: - - 4 C13V1333ii . I eso i 30 Twam-ii4Ac!in avnomuil 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 l&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) I IIC Registration Number Expiration Date HIC Company Name or I-IIC 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 .. 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 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 t is application is true and accurate to the best of my knowledge and understanding. PHI 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" eN,\ The Commonwealth of Massachusetts Department of Industrial Accidents 1�I ___ ,1 Office of Investigations Lafayette City Center _J 2 Avenue de Lafayette, Boston, MA 02111-1750 �,./ .f ssy www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information \An Please Print Legibly Name (Business/Organization/Individual): N_ w L r 7i1 Address: S 1 5 A bi `)e f r 1)' to City/State/Zip: kiti'. /b v t/ Phone #: 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. ❑ New construction 2.❑ I 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.* requi red.]ui 5. El We are a corporation and its 10.0 Electrical repairs or additions q ] officers have exercised their I l. Plumbingrepairs or additions 3. I am a homeowner doing all work n P myself. [No workers' comp. right of exemption per MGL 12.n Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.1 I Other comp. insurance required.] *Any applicant that checks box#l must also fill 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: 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 certif under the pains and penalties of perjury that the information provided above is tru and correct. Signature: Date: to-/ lJ �� Phone#: 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): i0Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5.E1Plumbing Inspector 6.DOther Contact Person: Phone#: ;. f-444_ , TOWN OF YARMOUTH z. � 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. 'Q .) -4 'C Work Address Is to bedisposed ofat the following location: -ro Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. /(7.1-/ Signature of Applicant Date Permit No. ( c ccr fla Li • F D Ti. j ' e E t t j 9l } • 1 . 6 1 } 1 -^ t• -' - t , • ._ ; 72-- ___ - — - ik...* a - - (0k L o-6 62 v:I_ et^ Vtaode_ 6.tc.DAsL_Nr Q4 [ 000-1)-- (04 Nicrue_ Sow � cJ 'wm . � ` ' ^^ , � . � � ^ - \ ----� ` ^ - ` ` ' ' . ' ` , . `|^ ' ` ' ` --' � ��