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HomeMy WebLinkAboutBLDR-26-562 application ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department ,mpg YA 1146 Route 28, South Yarmouth,MA 02664-4492_ Nrp �y . 508-398-2231 ext. 1261 Fax 508-398-0836 g (1 s;d Massachusetts State Building Code,780 CMR r--- _ Building Permit Application To Construct, Repair, Renovate Or}D es2 '4, RPCRAltO a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: R—Db— 3 Date Applied: CNCY14 aq Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Addre s: 1.2 Assessors Map& Parcel Numbers Lc> `dG,ikti►, or i2A 1.1 a Is this an accepted street?yes )( no Map Number Parcel Number 1.3 Zoning Information: ZZ 1.4 Property Dimensions: Zoning District Proposed se Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required, Provi Required Pro}�ided Reg7d /vided 1.6 Wateer SSupply:(M.G.L c.40,§54) 1.7 Flood Zone Informa/tion: 1.8 Sewage Disposal System: Public Private CI Zone: — Outside Flood Zone? Municipal❑ On site disposal system of Check if yesl8 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 1oAn m Yck tAi .?e�'� r'\ct 024) 7s Name(Print) City,State,ZIP /to 1Mo04" �.� l�� rl'TtjO . fi'Tr4e. t.e✓®Spit ,cowl No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 4t Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: R.& e@ c e] {iiy VIAL w. A% ‘.)e\t1L(V) 1'eiu1Qr vA5b11 CLt: ti,N" = 1c 5 '-t.v.c e A-5 -. t-c Ae SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ / 9 6 C° 1. Building Permit Fee:$_ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 25[^0 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ :47c 00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) L5 L,ct 4 b3ct '1lot it:2 1CIeo i u`,p. License Number Expiration Date Name of CSL Holder List CSL Type(see below) ism 1A oc_k No.and Street Type Description y� Unrestricted(Buildings up to 35,000 Cu.ft.) V vyto t ,Q✓� 1 • (,l C 1� R Restricted 1&2 Family Dwelling City own,State,ZIP M Masonry RC Roofing Covering WS Window and Siding n M� �/ l SF Solid Fuel Burning Appliances O)`•5G0 fl f�''i n E .►f( C d(NV BE i. f et I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /S3t a sf21 CA. C HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Mil address Yuv r,CLA.A � �u olici6 L-0375t 1t19 ty/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 ad 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 i.eAJ i v‘ ¶ .►/ to act on my behalf,in all matters relative to work authorized by this building permit application. 'obv► Jae bet ,4 . (?cz(. 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. VQA, p ( 1 0 12,4 /2Z,t 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 en 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents 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 Name (Business/Organization/Individual): 'C ,.^ \FL, Address: I kD O \---\ o,r,�/S tick �Z City/State/Zip:IA✓ 40 tA*V%�c t t 0u &2h,76 Phone #: /903 751(� Lt9 Are you an employ r? 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.[1 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 working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.t 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.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.171 Other 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: Ry - c cv n Policy#or Self-ins. Lic. #: Expiration Date: ,j"( 1 Z0 2,'7 Job Site Address: Z O ?7u,f T tMoc✓' \L City/State/Zip: po✓-d /-u V?v ZI Attach a copy of the workers' compensation policy declaration page(showing the policy n mber 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 he pains and penalties of perjury that the information provided above is true and correct. Signature: Date: e IL U l 7,(fL 4' Phone#: to 03 '�5 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 31:City/Town Clerk 4.0 Electrical Inspector 51=IPlumbing Inspector 6.0Other Contact Person: Phone#: ir— TOWN OF YARMOUTH . �� Office of the Building Commissioner `� ,-.. �,;� 1146 Route 28, South Yarmouth, MA 02664 `N° , 508-398-2231 ext. 1260 Fax 508-398-0836 �c:.Qp°BAtE� .yJ' 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. Z 0 -D3 if-6,,(!, c!'),'' Rd Work Address Is to bedisposed of at the following location: g JAM t A Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. ri,j -. ).-...:--. 40.-12 Signature of Applicant Date Permit No. Construction Supervisor les Commonwealth of Massachusetts Unrestricted- of any use group which space.s than 1 Division of Occupational Licensure 35,000rictecubic feet Buildings 91 cubic meters)of enclosed contain Board of Building Regulations and Standards Cons�l III 'b rvisor s CS 094639 ` acplres 0710112028 • x A KEVIN J FAI , .- ; 'tip+r , k 100 HOMERST • a fps F YARMOUTH � ;. �a + y.: '?P ��� s �^ , `' Failure to possess a current edition of the Massachusetts State PA r asy• Building Code is cause for r or viocation of it t is license. govldpllopsi yQi Contact OPSI:(617) Commissioner �e��:•._-- I Terms Agreement Payment Receipt Payment Confirmation YOUR PAYMENT HAS PROCESSED AND THIS IS YOUR RECEIPT Your account has been billed for the following transaction. You will receive a receipt via email. Office of Consumer Affairs and Business Regulation - HIC Registration Program One Federal Street, Suite 720 Boston, Massachusetts 02110 )0, Tla d :'IS.Vk!011 Pi oce.5S0 51,,it7t!•',0j!,ENv 8f'ilt':;A!bct-.Sa71--1( ::, • l • FetTelAregistration ,9Fcr000005y1A/JtEAM $100.00 $100 00 • I Date Paid: 9/8/2026 8:07:09 AM ET Convenience Fee: $2.59 Total Amount Paid: $102.59 Payment On Behalf Of Billing Information first Name: kevin First Name: kevin ast Name: fair Last Name: fair tAdress Address 1: 100 homers dock rd 5qtate/Territory: City: yarmouthport ip Code: State: Phone Number: MA (603) 759-0720 oZ2i Code:p675 . 1“1,ie Number: ■■■■■■■■.■■■ IMAM■■■■.■.■■■■■. ■■■N.■■.MM■■■■■■■■■■■■■■■■■■■■■■■ ■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■.■. ■■..■■I■M..■■■■■■■■■M■■■■.■■■■■■■ ■■■■■■■■■ ■N■■■■■■M■■■■■■■■■■■■NM 1■.■■■.■■■ ■■■■■■■■■■■■■■■■■■■■■.■ ■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■MM.■■■■.M■.■■■■■..■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ ■■■■■■■■.■■■■■■■■■■■■■■.■■■■■■■■■ ■■■.■■■■■■■■..■■■■■■■■■■ ■■..■■■■ ■■■■.■■■■■■■■■■■■■■■■■■■C■■■■■.■■ ■■■■■■■■■I.■■■■..N■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■I.■ ■■■■■■■■■■■■..■ ................................. ■■■■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■ :CC:■:■r■�':■■■■■■■■■MI■■■■::■:: ■■■■■■■I■■II1 PIIIM ■■NINEMIP 1M PIIIMI.. ■■■■■Cyr!.N■■rnr■11■■■■:1 ■!AP!©r■r ■■■■ ■■■■■II IS ■■EEI■11■■■■!'t1s'■ ■■■■■■■■ ■■■■■11MIU I`iil■■.N■■■■■■■■■■■■■■■ ■■■■■3■■■■U■■11■■■■MMUMM■■■■■■■ ■■■■■`aJrl�7■■!!11\■■hARI.I u r ■■■■■■ ■■■■N■\.■■■I11II■■■ 111. ex5 M■■■■ ■■■■■■■■■■■IMAM■■ gr'rv1 M■■■■ I■■■■■■[11W■■■Liii1■I■I. qZ0 ■■■■■ I■■■■■■!.MM■■11■■■■11111 11.111111... 1■■■■■■■.rNNN■..MM■■■■ ■I.....■ ■■■■.■■■■.M■■■.■■■■■■■■■■■■■■■■■■■ ■■■■■ EN.=■INIEN■■■■■■■■■■MMEM■ ■.■■■411711 MINA■■■■■■■■■m ■■■■■ ■■■■ EINEM■■■■11■■■■■■■■■■■■■■■■■■■■. ■■.Ml.R ■■■BSI■.■■■MINIM■■■■■■■■M■■ ■■■!�!! ■■■.�ill■■■■■■■■■■■■■■■■■ ■■ ■■■■E■!■■■■■II■■■■■■■■■■■■■■■■■■■■ ■■■■iN■■■L111.11■■■■■■■■■■■■■■■■■■■■ ■■■■■L°21111LINLII■■■■■■■■■■■■■MINI■■■ ■■■■!■■MIL I■■11■■M■■I■■■■■■■■■■■■I■ ■■■■■■U.■.■.■■■■■■■I■■■!■■■■■■■■. 11