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HomeMy WebLinkAboutBLDX-26-449 application • ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department _p'g' 71,4. 1146 Route 28, South Yarmouth,MA 02664-4492 .$ p047: ., 508-398-2231 ext. 1261 Fax 508-398-0836 r ' Massachusetts State Building Code, 780 CMR C H: ce Building Permit Application To Construct, Repair, Renovate Or Demolish ,Hco,.,cE[[.;b�q R , PORATEO a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 3L-Dy— ako-1149 Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 3 l+l p et i uk vie 1.1 a Is this an accepted street?yes + 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: Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: n ft 'cc.., Cod `/ wlDI Name(Print) City,State,ZIP 3 3 w1�,i,KJ �� 77/�i /O© O7O `-YCorahlt-1,ns�-Itcv Za►t .�-t( No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(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 0 Specify: Brief Description of Proposed Work' r-r t4,4 o h J ✓c Jr.r,Y UJ' Sd:Wi�t r'r ►+ncta, Gnu( ✓'< (lily e',rcPae 3h,.j/rf ( S�,.s.. 4z ® W. MAY SECTION 4:ESTIMATED CONSTRUCTION COSTS 0`- Estimated Costs: Item Official Use O y A TM NT (Labor and Materials) gU1LDING D 1.Building $ L c/ �iJZ� 1. Building Permit Fee:$ Indic e 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Costa tem 6 multiplier x 3.Plumbing $ 2. Other Fees: $ /00 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Total 1 Fees:$ Suppression) Ch No. Check Amount: Cash Amount 6.Total Project Cost: $ Paid in Full 0 Outstanding Balance TIGT7 • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) .�-, h_ ✓ tie?7r'3` /8/0l8 O , fJ� .f thet. License Number ExpifationDate Name of CSL Holder List CSL Type(see below) �1 23 1"1c/4 sYat l7S 4.)�c�/ No.and Street ` / Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) So Dt S priA da 4,4,p R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances COMV'60yy ,f‘v h<keac,cep Balmy . Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ' h,v‘,L-Tifrdfczi.i HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 71 LAC f'e S i G#/KyS sv r arse eP Kam; /-CCs•-r No.and Street Email address Sa 1).eti 1 5 iv1.6% O.(a6 D 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 fd nc 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 5t=5) vet >4/4-t1J ,gyp to act on my behalf, in all matters relative to work authorized by this building permit application. /j � Print Owner's Name(Electronic Signature) ate 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 r contained in this application is true and accurate to the best of my knowledge and understanding. >tA "`'eOhj"i oY1 i/ 30/,1l/ Print Owner's or Authorize Agent's Name(Electronic Signature) ! ate NOTES: I. 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" i ', v 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 Revised 7-2019 www.mass.gov/dia TOWN OF YARMOUTH Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 :sfe :ST «e ;> 508-398-2231 ext. 1260 Fax 508-398-0836 `~ cgp0R4TE��b-� HOMEOWNER LICENSE EXEMPTION DATE: JOB LOCATION: 1-7.42 . 4/6/ '#st) 33 KGV'✓1 r row/ NAME STREETADDRESS SECTION OF TOWN HOMEOWNER . 9L, ., ),)� , .�, ('- �, fr, v-1-1 77 f/ O " -0 NAME HOME PHONE WORK PHONE PRE ENT MAILING ADDRESS j //ier71ii1c CITY OR TOWN STATE ZIP CODE Definition of } Iomeowner: Person(s) who owns a parcel of land 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/or farm 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 of 780 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 110.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 - �,y t'1�--- • -x-ciE4s, TOWN OF YARMOUTH fo> Office of the Building Commissioner ,ceY 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. 33 wiir,,,ti� o(1 i/arr�,q/y4 Work Address 7— Is to bedisposed of at the following location: yor/rifu'/I `72Ji7 .Jig Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111,§150A. 674Date ignature of Applicant Date Permit No. The Commonwealth of Massachusetts Department of Industrial Accidents `1 -----. . .yY Office of Investigations ii, -_..- .- �. l Lafayette City Center ; r-J �' ' ' 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dca Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): j,,ri, Address: 5`7-4frii.y-s hde-y' 3e) O t t et O RVV City/State/Zip: Phone #: 30 6 ‘DrY Are you an employer? Check the appropriate box: Type of project (required): 1 . ❑ I am a employer with 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2. K 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' p y 9. ❑ Building addition [No workers' comp. insurance comp. insurance., required.] 5. ❑ We are a corporation and its 10.❑ 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.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.❑ Other 7;v1,J z;,,s.t id,,,464.6 comp. insurance required.] £ 54 h4 4 hie- ja; i,,t *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I. 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: v— /..---1 /- �// .„_ Date: //ge)/14.:, Phone #: - 9 0a Of:// �.i Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Y Issuing Authority (check one): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone #: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR • , TYPE:Individual t' Registration `"` Expiration 186029 06/10/2026 JOSHUA F THIBEAU JOSHUA THIBEAU 73 UNCLE STANLEYS WAY ' ' SOUTH DENNIS,MA 02660 Undersecretary Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards tI t St • CS-109745 spires: 04/08/2026 JOSHUA THtEAU 4 s 73 UNCLE STANLETSWAlf, SOUTH DEN MA **MO > ._ � F CommissionerMr! 5 • 5/2/26,7:52 AM Mail-King,Jennifer Lynn-Outlook Commonwealth of Massachusetts Construction Supervisor Division of Occupational Llcensurc Unrestricted-Bulktings of any use group which contain less than Board of Budding ite uiations and Standards 3s,000 cubic feet(9S1 cubic meters)of enclosed space.. Consstt a trt(t'pprvisor CS-109745 stie, dpires 04/08/2028 JOSHUA TH tEAL :�. 73 UNCLE SYANtr • SOUTH DENN1)S 1` - SEA ter-�,a� �,, i I^4 t� � � =' allure to possess a currant edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner C t it/a4f Contact OPSI:(617)727.3200 or visit www.mass.govidpiiopsi https://outlook.cloud.microsoft/mail/inbox/id/AAQkAGUSZDgwYjJiLWMSZDEtNDc0My05NDk4LW RjODVhMTVjZGEONwAQAMoHCIRd3PxNrvgE%2B... 1/