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Home My WebLink AboutBLDR-26-95 application /1 ,. R E C E I V E OE & TWO FAMILY ONLY- BUILDING PERMIT __ Town of Yarmouth Building Department p Y`��4�� MAR .. 0 2026 1146 Route 28, South Yarmouth,MA 02664-4492 �� p 508-398-2231 ext. 1261 Fax 508-398-0836 f Massachusetts State Building Code, 780 CMR MATTAC Me Ri BUILDING ,�EFARTN�E nilding permit Application To Construct, Repair, Renovate Or Demolish -"co, nnnTfla`b'''' 12.3�. ` - - a One-or Two-Family Dwelling " 7I I]P n This Section For Official Use Only Building Permit Number: "• 21 ,51 Date Applied: Build 'al(Print Name) Signature Date jr SECTION 1: SITE INFORMATION 1.1 Pro . Address: 1.2 Assessors Map&Parcel Numbers 3 9'1 1.c9G1, tie 2 b l.la Is this an accepted street?yes 6 no Map Number Parcel Number 1.3 Zoning Information: j� 1.4 Property Ditpensions: Zoning District /Proposefl Use Lot Area(sq ft) Front ge(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided /• /7 , / 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 11/ Private 0 Municipal 0 On site disposal system 1;1�� Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 3'9 l t . (t1L '2.0 9AtZrn(234)T 1,-` rv.so, oz�.-7< Name(Print) City,State,ZIP ,_4. By-reJQ-+-6' PQegt_ VAc rd14 -,lam ?go c .-- No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building I12'--Owner-Occupied IB f Repairs(s) kOAlteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'-: l�.L,tiys+ 1- y7.„-f-A. SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs:Item Official Only `K � (Labor and Materials) Use `, 1.Building $ 1. Building Permit Fee:$ 3 Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) S List: 5.Mechanical (Fire S — Suppression) Total All Fees:$ ,a Check No. Check Amount: Cash Amount: Z 6.Total Project Cost: S �Z�l 6,ac ❑Paid in Full 0 Outstanding Balance Due: - ' '4 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) 0 ilig2e Dek 50 a ` a A- C .o -Z. .taa License Number Ex iratio Date Name of CSL Holder List CSL Type (see below) is- 4:;30 `f � ----No. and Street Type Description U Unrestricted (Buildings up to 35,000 cu. ft.) c t Le.e K.) 4-- v I R Restricted 1 &2 Family Dwelling e l g City/Town, State, ZIP M Masonry M A . ‹ RC Roofing Covering /�Y''''� cot.) ��"'' 7 WS Window and Siding SF Solid Fuel Burning Appliances ob OdS • 4-.2 --4. '4 ) 11 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor (HIC) 106 () cr te ) 2-' zo .d 4Pe'1-21,4j-,P 1-1 A itiLe 2-10-e HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 4 l 0 IL ZS e r ) S /V , �AA e?i,j No. anStreet M Email address 7 ‹- 1 4--,ev,, A; 4 qne City/Town, State, ZIP 6 14-7'5 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 . 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT d, a 2e e ;2 i 0-0, I, as Owner of the subject property, hereby authorize `''-- ' — .5 to act on my behalf, in all matters relative to work authorized by this building permit application. ishite-r.,____.er.._ .Te7_24- Prin 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 conta. ed in this ap91 ation is true and accurate to the best of my knowledge and understanding. eiietild, @( 4e-1-'1-1 _ /,6 /P40 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 vww.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" TOWN OF YARMOUTH Office of the Building Commissioner r(g South Yarmouth, MA 02664 ° _ 1146 Route 28, ~cO4PORSEO'1yG 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 7 g alga- l Work Address ed of at the followinglocation: }tmt�t5 rt" L W N� c 1- Is tobedispos Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. L__3/q/26 gnature of Applicant Date Permit No. • The Commonwealth of Massachusetts Department of Industrial Accidents =w4l- Office of Investigations ? 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 11 Name (Business/Organization/Individual): �! n n,L d. L-k- t'jl ►2_d)e Address: 0 1 -eA) City/State/Zip: y fAv'VY/ 001-VI 1114 &..Q67 hon —e #: �d� � tp 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 ployees (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. n Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h'• 9. ❑Building addition [No workers' comp. insurance comp. 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 11.0 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.❑ Other I comp. insurance required.] �" *My 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 certi nder the i i % s a d penalties of perjury that the information provided above is true and correct. Si ature: Iwo / Z�%l Date: 3 q / l Phone#: J 0 r> 40.4c5/ 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): 11::IBoard of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing 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 Revised 7-2019 Fax (617) 727-7749 www.mass.gov/dia , .,. -.......... i• 1 I ! , I .......:;:- — ----IT ft.... 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Q 1, t / i ) eP:e...s_ -........ --- I ',.......,,,........ -___ x 3 Lc � i Licensee Details Demographic Information ;Full Name:,Owner Name_ Donald J Harkenrider License Address information City: Yarmouth Port State: MA ..ipcode: 02675 ,Country: United States } License Information License No: CS-014978 License Type:' Construction Supervisor ;Professioe: Building Licenses Date of Last Renewal: 4I10I2024 !Issue Date: 5/12/2010 Expiration Date: 5/12/2026 ;License Status: Active Expiration Date: 5/10 204 Secondary License Type: Doing Business As: ?Status Change Reason: License Renewal ' Prerequisite Information No Prerequisite Information -�~ - -- No Available Documents_.____ _____ commonwealth of Massachusetts ,, `-' Division of Occupational Licensure } Board of Buiidina Regulations and Standards OOr St ;On tU5 r1iiS0r .. _ . empires: 0511212024 CS-014978 r- DONALD J HARKENRIDER 20 EILEEN ST YARMOUTH TORT MA 02675 _ Commissioner eAue fi. tiayulLw.., COMMONWEALTH OFMASSACHUSETTS Registration valid for individual useo only before the HE COMMONWRegulation expiration date. If found return Office of HOME IMPROVEMENT Aairs Cu TRACTORlation Office of Consumer Affairs and B1ssiness Reg HOME E:Individual 1000 Washington Street - Suite 7 Expiration Boston, MA 02118 100909 Re ion 06! /32 2026 DONALD HARKENRIDER DIB/A DONALD J. HARKENRIDER , s //i/ .- DONALD J. HARKENRIDER ' -644 teli;(:' / - X-4-...‹.6;e1-:(e- , 20 EILEEN STREET Na valid without signature YARMc�UTH, NIA 02675 Undersecretary