HomeMy WebLinkAboutBuilding Permits BackfileOF r� TOWN OF YARMOUTH Building Department BUILDING
(508) 398-2231 ext.261
PERMIT NO F6-04-1442 ' PERMIT
ISSUE DATE ; _ 6/25/2004 _ PROPOSED USE - - - - - - - - -
- Gleason -------------------' JOB WEATHER CARD
APPLICANT Marion Gleason
------------------------------
PERMIT TO Addition
------------
AT (LOCATION) 100041ELLISCIR ZONING DISTRIC R-40 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1133.23 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-4
LOT SIZE ICONTRACTOR
construct UP
d patio as per plans dated 06/22/04.
REMARKS
AREA (SO FT) EST COST ($ $8,500.00 PERMIT FEE ($) 1$148.00
OWNER IMARION K GLEASON BUILDING DEPT BY
ADDRESS 385 Mass Ave.
Arlington MA 02474
INSPECTION RECORD
LICENSE 0
FIELD COPY
Date I Note Progress - Corrections and Remarks I Inspector
D
oF'YgR,� ONE & TWO FAMILY ONLY - BUILDING PERMIT
$ p APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
p— y Town of Yarmouth Building Department
„ r,;;C„«S 3 1146 Route 28 • Yarmouth, MA 02664-4492
Tel: (508) 398-2231 x261 • Fax: (508) 398-0836
Office Use Only
Permit No. - '11"')Ba
Permit Fee $ N9, .-
Deposit Rec'd. 0S/06 Da
Net Due
Planning Board Information Assessors Department Information:
EAdo7Type Map Lot
rsement Date
Recording Date New
No
1.4 Property Dimensions:
Lot Area (st) Frontage (ff) Lot Coverage
This Section for Office Use Only
Building Per Number
Date Issued:
9�i �
Signature: 6 .-/' ,
Certificate of Occupancy
is is not required
Building Official Date
Section 1 - Site Information I Use Group: R-4 Type: 5-B
1.1 Property Address:
y/ CtLiS c1kClc
1.2 Zoning Information:
g(o
Zoning District Proposed Use
OY-
1.3 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
1.4 Water Supply (M.G.L. c. 40. S 54)
Public Private
1.5 Flood Zone Information: Comments:
Zone: BFE:
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Record:
//1 A R rota K. GLE Dr-)
Name (print)
(P )
Signature
Sn
Mailing Address
Telephone
A_-c HvLr ALA44AI AQ(1.
2.2 Authorized Agent:
Name (print)
(p )
Signature Telephone
Mailing Address
Fax
D
I ij 5
iit
I:!Ir
AY 1 2 04 !=
i
By --
Section 3 - Construction Services
3.1 Licensed Construction Supervisor:
Not Applicable
t
License Number
Address
Expiration Date
Signature Telephone Uy
3.2 Registered Home Improvement Contractor:
Company Name
Not Applicable ar
Address
Signature Telephone
License Number
Expiration Date
754
1 of 2 OVER
Section 4 - Workers' Compensation Insurance Affidavit (M.G.L. c. 152S 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 5 -;Description of Proposed Work, (check all applicable),
New Construction I No. of Bedrooms No. of Bathrooms
Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work:
Section 6 - Estimated Construction
Costs
Item
Estimated Cost (Dollars) to be
completed by permit applicant
Check Below
Conservation -Commission Filing
(if applicable)
,/
I_J Old Kings Highway & Historical
Commission approval
(if applicable)
1. Building
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5)
7. Total Square Ft. (new houses R additions)
Epp -
Section 7a - Owner Authorization -
Owner's Agent or Contractor Applies
To be Completed When
for Building Permit
I, M AP, $ r) N K. G L-f=-4So i`% as owner of the subject property
hereby authorize f Yl I KE Mco t% 1 R O S to act on
my behalf, in all matters relative to work authorized by this building permit application.
Qhxr7l j K, / 7 , .�o 0 it
ignature of Owner Date
Section 7b - Owner/Authorized Agent Declaration
I, /11" ro fJ k'. GCEA-SO0 , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
MRAt0A) /G Gt Asor�
Print name ' `
Signature of Owner/Agent Date
9-15-99
2of2
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the `reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work:
Address of Work
Owner Name:
Date of Permit Application:
I hereby certify that:
Est. Cost
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
•'
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
i 7Jq0 d Y
Dat Owner Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oxceof1"esdpstbss
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
rl I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
1 am an employer pro%iding workers' compensation for my employees working on this job.
company name:
address:
may. phone sh
insurance co policy #
I am a sole proprietor. general contractor, or homeowner (circle one) and have hired the contractors listed below ssho have
the follo%%ing %corkers' compensation polices:
company name:
city phone #-
insurance co policy #
company name:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of A fine ap to S1,500.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature Date
Print name Phone M
olricial use only do not write in this area to be completed by city or town official
city or town: YARMOUTIL
[] check if immediate response is required
contact person:
permit/license tt nBuilding Department
[]Licensing Board
261 []Selectmen's Office
[]Health Department
phone a: _ (508) 398-2231 ext. riOther
Ironed 3,91 PJA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
entplo� ees. As quoted from the "law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An enrplt!ver is defined as an indi% idual. 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
o%%ner 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 wounds or building appurtenant thereto shall not because of such emploNment be deemed to be an emplo%er.
MGI_ chapter 152 section 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, neither the commomvealth nor any of its political subdivisions shall enter into any contract for the
performance of public \%ork until acceptable evidence of compliance with the insurance requirements of this chapter hay e
been presented to the contracting authority.
Applicants
Please till in the workers' compensation affidavit completely, by checking the box that applies to your situation and
suppl\ in= company names. address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affida% it 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 %Norkers' compensation policy. please call the Department at the number listed below.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of investigations would like to thank you in advance for you 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 lanes 13111eos
600 Washington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 7274900 ext. 406, 409 or 375
of YARD TOWN OF YARMOUTH
oc
_ BUILDING DEPARTMENT
r 1146 Route 28, South Yarmouth NIA 02664 508-398-2231 ext. 260
•. w�rtwcn�s(� �tl
� 1
A @ HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: /,I, y 1 YJ , ao o `f
JOB LOCATION: /// 4�5_LLlS GRGI, \/ARM0U44-A"ODV*
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" Z?j4R%yN k' G A,SO&I 7,?/-le V/-0A'&t/
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS Sr 5 iYl4 s 5 Q[.0 AA1 f o
,40Li N 97aN M4 6a6475!f
CITY OR TOWN STATE ZIP CODE
The current exemption for `Homeowner' was extended to include owner — occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that such
homeowner shall act as supervisor. (State Building Code Section 108.3.5.1)
Definition of Homeowner:
Person(s) who owns a parcel of land on which he / she resides or intends to reside, on which there is or is intended
to be, a one or two family attached or detached structure assessory 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; such "homeowner"
shall submit to the building official, on a form acceptable to the building official, that he / she shall be responsible for
all such work performed under the building I ermit. (Section 108.3.5.1)
The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned `homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE //(Glun+i , -d4_,n�
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142.
Yes ❑ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
'K AP,cca, Check one•
Signature of Owner or Owner's Agent Owner Agent ❑
h:homeownrlicexemp
TOWN OF YARMOUTH
1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
//
conducted at '�`"Z1�� �'1
Work Address
is to be disposed of at the following locatio �� U
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Applicant
Permit No.
Date
"ARMOUM Old King's Highway Regional Historic District CornlniVie�.� j L) l._ TH
in the Town of Yarmouth for a TO, V t'-1, 1 r R K
M JUN 12 AN 9: 4 8
CERTIFICATE OF APPROPRIATENESS D ' � J
IT
ation is hereby made in triplicate, for the issuance of a Certificate of Apprapfii6eion 6
tpter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on
drawings or photographs accompanying this application for.
CHECK CATEGORIES THAT APPLY:
1. Exticrior Building Construction : ❑ New Building ❑ Addition ❑ Alteration
fimb We typeofbuiWmg ❑ House ❑ Garage ❑ Commercial ❑ Other
2. F-xt xior Painting: ❑
3. Sigr s or Billboards: ❑ New Sign ❑ Foisting Sign ❑ Repainting existing sign r
4. S ❑ Fence ❑ Wall ❑ Flagpole 0 Other rr r.ri � � 1� a±o
TYPE OR PRINT LEGIBLY
OF PROPOSED WORK �( ELLr c ., r 'la ASSESSORS MAP NO. 133
ASSESSORS LOT NO.;_
ADDRESS 4� 11 rc'///5 Ov-c(o r k[Aa mo ,_+,pp ' TELEPHONE NO. ,-5Q9 - ,3 6 Q - 6:Yq
OR CONTRACTOR Plu C 1 L 1 TELEPHONE NO-�-L I
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERS
DE¢, TAED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done including materials to
be used II In case of signs, give locations of Busting signs and proposed locations of new signs. (Attach additional sheet, if
nET)_
Check
Signed Z>�Lsr•: � ,LyG�een—.
Owner -Contractor -Agent
This Certificate is Wei ( �;1 Date COP/,
❑ DIPORTMUV If Certificate is approved, approval is subject to the 10 day appeal period
provided in the Act.
D Please return to: Yarmouth OKHC District Committee
Yarmouth Tonm Hall, 1146 Route 28, S. Yarmouth, MA 02664
? A . Aft C
fill
SPECIFICATION SHEET (YARMOUTH OKHC)
out the form in its entire providing r'�' ' ,In I&re
INDICATE LANDSCAPINGEXTERI R IGHTING g L'M TE
V HOUSES
2913 AN 12 AM 9: 49
RECENED
DRIVEWAY:
(18" MAX. EXPOSED): CONCRETE/OTHER
WA LK WAY: STEPS (INDICATE BRICK/CEMENT/OTHER):
SIDI NG TYPE & MATERIAL: COLOR: -
CHI VfNEY (INDICATE BRICK/STUCCO/WOODFACED) COLOR:
RO F MATERIAL. PITCH (7112 MIN.) COLOR:
MAX EXP.
OWS (GRILLES REQUIRED}—(WOOD/OTHER)
NDI ATE SIZES IF NOT LISTED ON ELEVATIONS:
(WOOD/OTHER)
i SIZES AND STYLE IF NOT LISTED ON ELEVATIONS): COLOR:
T
: (ALL WINDOWS & DOORS TRII AED WITH IXa / IX5)
COLOR:
MA71
ERL4,L OF TRIM: (WOOD, VINYL, ALumDR M)
SEW
MRS (WOOD/VRM) (PANELED/LOUVERED)
COLOR:
G
RS (WOOD/ALUMIrrr1M):
COLOR
G
WE DOORS: SIZE & STYLE:
COLOR:
STO
WINDOWS & DOORS:
COLOR:
(INDICATE
SIZES IF NOT LISTED ON ELVATIONS)
S
GHTS: TYPE/SIZE: 4 X I D rnamrspn Pd+2C i
colon:
i o y l I P".4
WO
D DECK: SIZE: -A - =-j^ 4.g4LIr AAA" ,`
`
� ,
COLORt4F! t
WO
FENCING (MAX. HEIGHT 6'): STYLE:
COLOR
(SHO
LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
RETA
INING WALL: (P. .j0FIELDSTONE NCRETE INAPPROPRIATE)
(SHO
.
LAYOUT &RUNNING PLANy, ., .
'ZRIC►, _ n t
r �T
SIGN
(indicate size, style, colors)
COLOR:
SIGNPOST:
(indicate size, style, color) �i0 -" fin;,,
COLOR:
ADDI
ONAL
INFOT
MATION:
REV. I
o2
TOWN OF YARMOUTH
Building Department
Town Hail
Yarmouth, MA 02664
(508) 398-2231 ext.261
BUILDING PERMIT
APPLICATION RECEIPT
Temp Permit No.:
Applicant Name:
T-04-587
Marion Gleason
Location: 00041 ELLIS CIR
Owner's Name: MARION K GLEASON
Owner's Addres 385 Mass Ave.
Arlington - MA 02474
Owner's Telephone: (781) 641-0634
(OFFICE USE ONLY
Recorded By:
Ic
Permit Fee:
$0.00
Deposit Rec:
$25.00
Payment Type:
Cash ChkNo.: 0
Net Owed:
($25.00)
Application Date:
5/18/2004
Issue Date:
Expiration Date
Comments:
33
construct two decks and patio
ZONING APPROVED
LY- <J/
This is NOT a building permit. Application subject to plan review. Contact Building Department for permit status. Official
Building Permit will be issued upon plan review completion, approval, and complete payment of Net Owed on Permit Fee.
Date Printed: 6/15/2004
0�.
.0 Y'tR
MATTA M. st
4M.4..rtI
Building Site Location:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
TRANSMITTAL SHEET
Map No: _/_ _33 Lot No: a -3
9 i ,
Proposed Improvement:
Address:
1
-))zA v12
The Building Department will be responsible for assisting the appli
applicable departments.
Tel.No.: &Z,Vzloate Filed: S
dispatching your plans and or application to the following
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT:
Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT:
Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION:
Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT:
Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT:
Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
---------------------------------------------------------------- - --------------------------------------------------------------------------
REVIEWED BY:
1. WATER DEPARTMENT:
DATE: /A:
/
2. ENGINEERING DEPARTMENT:
DATE: N/A:
CONSERVATION:
4: HEALTH DEPARTMENT: DATE: NIA --
S. WIRING INSPECTOR:
INDUSTRIAL AND/OR COMMERCIAL PERMITS
DATE: N/A:
6. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: C DATE: N/A
�j PLEASE NOTE
0
rAtr-/d LolLL LSF
12�Qu/2�<
RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE:
White copy - Building Dept. - Pink copy - Water Dept - Yellow Copy - HaM Imo• - Pink Copy - Engrg Dept - Goldenrod - Fire DgWCoavQvuion
V
LOT 26 . - ._..— 'rno_ �•�.�
29� 24.3' LOT 25
64 AS/LOT A251 ti
o.
D ; � • 9- � ' -
a-:cn.a.6
turn IV AL
v,
CB ALL
AL
AL
,ivi+ i 1 cD'• � i
RES. ZONE"R40" This VORTGAGE INSPECTION Plan u For FLOOD ZONE.- MC" TOWN: - REGISTRY OWNER GrE12B_GF !__Q1ZN-f- __----------------
P---------- -
DEED REF: _1424 42r�._____------BUYER: �if681Q� K GL,S01Y---------------------------
DATE: _Y1241S6--------------- PLAN REF:-1,1L4! ck_----SCALE:1"= 40 --- FT.
I HEREBY CERT FY TO BQ.FT 1r of
!!'_FA't�ILL—�
_s_a_Ncs BAN THAT THE BUILDING YANKEE SURVEY
SHOWN ON THIS PLAN IS LOCATED ON E GROUND AS ?� PA
THULCONSULTANTS
SHOWN AND THAT ITS POSITION DOES CONFORM o MEAXHEV H 40B (SUITE i)
TO THE ZONING LAW SETBACK REQUIREMENTS OF THE No.32M ! INDUSTRY ROAD
TOWN OF 1MMAA2VTH AND THAT
1T DOES NOT LIE WITHIN THE SPECIAL FLOOD HAZARD �ISTfRE% MARSTON$ MILIS. HA. 02"S
AREA AS SHOWN ON THE H.U.D. MAP DATED/-2P1,9� _ �0��< <xNas TEL:- 428-0055
o — 250015 0001 D FAX 420—
THIS PLAN NOT MADE FROM AN INSTRUMENT
�AnT—A—•tiTt�+}�QVw"_"mrK•�---� ertntmV &rn.n Tn nC Ttgrn mp rpmrFC i'•TI- 24483 D�.B A
..RRsi TH 9RLEAM g, , gh Y Regional W ° R N,1 O U TH
r.R"IAS oREWSrE Old Kin s Hl w,a Re onal Historic District Commi Ci;
in the Town of Yarmouth for a
TOWN C'l_ERK
CERTIFICATE OF APPROPRIATENESS'D3 JUI4 12 AN 9: y 8
Application is hereby made in triplicate, for the issuance of a Certificate of AppralLL 6e ion 6
of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on
plans, drawings or photographs accompanying this application for.
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction : ❑ New Building ❑ Addition ❑ Alteration
Indicate type of building: ❑ House ❑ Garage ❑ Commercial ❑ Other
2. Exterior Painting: ❑
3. Signs or Billboards. ❑ New Sign ❑ Existing Sign ❑ Repainting existing sign
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other na. ko aaJ A Q.cl k-
4
TYPE OR PRINT LEGIBLY DATE
ADDRESS OF PROPOSED "WORK V ELLt s 6 r Jd ASSESSORS MAP NO. /33
OWNER D1 o tJ tc G[ 6,SAsonJ ASSESSORS LOT NO.cZ?
HOME ADDRESS 4(L E'l/rsn Grcf (3 DKVAamo ,por TELEPHONE NO. 50S - 31 a -,53-71
AGENT OR CONTRACTOR Plu l.Sl-Q.t�e� TELEPHONE NO
ADDRESS
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERS
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done including materials to
be used In case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if
necessary).
SignedZGt 2u *% /� Clf�ean-
-Agent
Owner -Contractor
Space below line for Committee use only.
Received by OKHC
Date s l�i - This
Certificate
nnis hnZ'
/Daatt.e A6-1Check #
�
4 v
By
APPROVED ❑ 1 PORT If Certificate is approved, approval is subject to the 10 day appeal period
provided in the Act.
DISAPPROVED ❑ Please return to: Yarmouth OKHC District Committee
Yarmouth Town Hall, 1146 Route 28, S. Yarmouth, MA 02664
SPECIFICATION SHEET (YARMOUTH OKHQ
Please fill out the form hi its entirety providing �r� RT - re
necessary. INDICATE LANDSCAPING, EXTERIOR LIGHTING & EL Rl \ ITE
PLANS FOR NEW HOUSES.
2413 AN 12 All 9. 44
ADDRESS: �� �l�i ,S ��G��
RECEIVED
FOUNDATION (18" MAX. EXPOSED): CONCRETEIOTHER DRIVEWAY:
WALKWAY: STEPS (INDICATE BRICK/CEMENT/OTHER):
SIDING TYPE & MATERIAL:
CHIMNEY (INDICATE BRICK/STUCCO/WOODFACED)
ROOF MATERIAL: PITCH (7/12 MIN.)
MAX. EXP.
WINDOWS (GRILLES REQUIRED"WOOD/OTHER)
INDICATE SIZES IF NOT LISTED ON ELEVATIONS:
DOORS (WOOD/OTHER)
(INDICATE SIZES AND STYLE IF NOT LISTED ON ELEVATIONS):
TRIM: (ALL WINDOWS & DOORS 'IRRvB4ED WITH 1X4 / 1X5)
MATERIAL OF TRIM: (WOOD, VINYL, ALUMINUM
SHUTTERS (WOOD/VINYL) (PANELED/LOUVERED)
GUTTERS (WOOD/ALUMINUM:
GARAGE DOORS: SIZE & STYLE:
STORM WINDOWS & DOORS:
(INDICATE SIZES IF NOT LISTED ON ELVATIONS)
SKYLIGHTS: TYPE/SIZE: 4 X / 0 PoQCpI
1(� X 2 1 p►�-ri �
WOOD DECK: Sim:
WOOD FENCING (MAX. HEIGHT 6): STYLE:
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
COLOR:
COLOR:
COLOR:
COLOR:
COLOR:
COLOR:
COLOR:
COLOR:
COLOR:
COLOR: �-
COLOR
COLOR:
RETAINING WALL: (P. . OR FIELDSTONE.- NCRETE INAPPROPRIATE)
(SHOW LAYOUT & RUNNING PLIIAM--.tr-,
SIGNS: (indicate size le ->-! L
sty colors ) i ;. i COLOR:
Y r�
SIGN POST: (indicate size, style, color) "'CU7N Col., 1 COLOR:
I OKIlp s
ADDITIONAL i
INFORMATION:
M�
• may' : ,... -..:
REV. 12/02
30-4(by
.0 Y R: 5�� TOWN OF YARMOUTH F
y� o
C X� v ' BUILDING DEPARTMENT
i
O y
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
TRANSMITTAL SHEET
Building Site Location:
Proposed Improvement:
Ancfti'Faiitr' — �JG /J� ,rLi C;
Address: 1-)jsc� LLa-P_ L
�C� D
The Building Department will be responsible for assisting the apl
applicable departments.
No: _/ 33 Lot No: 123
Tel.No.: 1k1 e V&,.Date Filed.
dispatching your plans and or application to the following
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
-----------------------------------------------------------------------------------------------------------------------------------------------------
VIEWEDBY:
1. WATER DEPARTMENT:
DATE: N/A:
2. ENGINEERING DEPARTMENT:
DATE: N/A:
:COTVSERVATION:-- ��
/ / -- -- - - - f
// DATE:�-�(� G N/A
¢� HEALTH DEPARTMENT:
v
DATE: N/A:
S. WIRING INSPECTOR:
INDUSTRIAL AND/OR COMMERCW. PERMYTS
DATE: N/A:
6. PLUMBING INSPECTOR:
DATE: N/A:
7. FIRE DEPARTMENT:
DATE: N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY:
SIGNATURE OF APPLICANT: DATE:
Whft CM - Buddmg Deft - Pmk W" - WaW Dept - Yellow Copy - Halm Dept - Pink COPS -> 8 Dept - 0oldeomd - Fka DepilC.onaavatmp ,
t
TOWN OF YARMOUTH
BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
TRANSMITTAL SHEET
Building Site Location:
Proposed Improvement:
Address:
The Building Department will be responsible for
applicable departments.
No: __L33 Lot No: a 3
. 1 "
dispatching your plans and or application to the following
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determues Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
-----------------------------------------------------------------------------------------------------------------------------------------------------
REVIEWED BY:
V I. WATER DEPARTMENT: DATE: N/A:
2. ENGINEERING DEPARTMENT: DATE: N/A:
/CONSERVATION:
i 4. HEALTH DEPART.
5. WIRING INSPECTOR: DATE: N/A:
6. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A:
COMMENTS:
RECEIPT OF COPY:
PLEASE NOTE
SIGNATURE OF APPLICANT:
DATE:
G319@FS0WMD
JUN 1 6 2004
HEALTH DEPT.
White copy -Building Dept - Pink capy - Water DepL - Yellow Copy -Haft tom• - Pink Copy - Engineering Dept - Goldetnod - Fire MptAConsmation
N o sr r C S � n,�� c � , t C-�Vp / .,A ".,L,
a
ch5
I
i
LOT 26 hy� . . — 0 AUG 23 pm- 1a:
0 24.3 LOT 25
AS/LOT A25� ,U ,
Cgs
0'
0
; 00
A
IL
AL
RES. ZONE- "R40" This ORTGAGE INSPECTION Plan is
Bank u
TOWN: _ ,&= __________ REGISTRY OWNER: _C4'QB9FJ_,
DEED REF: _142� 4.A__—_--_____BUYER: �If6B1Q� FLSilGlY__.
DATE: _2��4�,99________________ PLAN REF: _1ddZVZL&_
I HEREBY CERTIFY TO BQSjQIL EDERjL_ to or
SA VINCS BANK(
THAT THE BUILDING !
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS PAUL
SHOWN AND THAT ITS POSITION DOES CONFORM ,�_, A.
1vtEA1TFIEW
TO THE ZONING LAW SETBACK REQUIREMENTS OF THE Na,
TOWN OF _yA8MQ11TH AND THAT
IT DOES NOT LIE WITHIN THE SPECIAL FLOOD HAZARD ��rsrtaE°,
AREA AS SHOWN ON THE H.U.D. MAP DATED 7/0V.M_ �Oa�< uK°S�
. mAnr—Ar—avnvmtr J—ET'w� o:.ntn+v-vnin-Tn nc• imrn rnp rrmrrq vTr-
AL
m&
n FLOOD ZONE: "C"
�G ------------------
SCALE:1„_— 40 -- --- F T.
YANKEE SURVEY
C 0 NS ULTANTS
40B (SUITE 1)
INDUSTRY ROAD
MARSTONS MILIS. MA 02548
TEL 428-0055
FAX 420-5553
24483 DiCB
A
FIELD COPY
� 3a�
' BUILDING
-f
PERMIT
DATE Rl 2001 PERMIT NO. B-01-579
APPLICANT Tl "� D /�t`lttn ADDRESS it Pond Street' 14_ Dennis n742os
(NO.) (STREET) (CONTR'S LICENSE)
NUMBER OF
PERMIT TO addition (_) STORY DWELLING UNITS
roan PnSF❑ USE)
(TYPE OF IMPKUVLM"I1 -0.
ZONING
AT(LOCATION) 41 Ellis Circle Y P 02675 DISTRICTO
(NO.) (STREET)
y BETWEEN AND
rn (CROSS STREET) (CROSS STREET)
LOT
IL SUBDIVISION 13•'}J 32 LOT Nsn BLOCKMap 714 SIZE.-5-�
�^ FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
4m BUILDING IS TO BE FT. WIDE BY
O
Z 5 $ USE GROUP R BASEMENT WALLS OR FOUNDATION —
TO TYPE
0
O
LL 1 t
REMARKS: A[�r�ifiC
AREA OR
VOLUME.
(CUBIC/SQUARE FEET)
(TYPE)
PERMIT $ 1 sn_nn
ESTIMATED COST FEE
OWNER Marion Gleason BUILDING DEPT
ADDRESS 385 Mass Ave Arlington MA 07474 B) n
f
INSPECTION RECORD
DATE NOTE PROGRESS - CORRECTIONS AND REMARKS
INSPECTOR
3 ev
7—,2—o1
99
C
C
C
of YAR ONE & TWO FAMILY ONLY - BUILDING PERMIT ' V
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OZTWO FAMILY DWELLING
Town of Yarmouth Building Department
N „ r.;;C„DES 2 _ 1146 Route 28 - Yarmouth, MA 02664-4492
IDl 4erran.n�'G
2 Tel: (508) 398-2231 x261 •Fax: (508). 398-2365
Office Use Only
Permit No. /— ate3 )
Permit Fee $ /5 Q. —
Deposit Rec d. Dat Q/
Net Due $�76• l l
Planning Board Information
Plan Type
Endorsement Date
Recording Date
Plan No.
Other
Assessors Department Information:
Map Lot Ma Lot
t Q o �3 31�
Old New
1.4 Property Dimensions:
f
Lot Area (sl)•sFrontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number: J
Date Issued:
Signature:
Certificate of Occupanc
is is not required
Building Official Date
Section 1 - Site Information I Use Group: R-4 Type: 5-13_
1.1 Property Address:
E►11S C�1rc.I c:
1.2 Zoning Information:
jZV--s /2,yo
Zoning District Proposed Use
VA Y- M O L) 114 A
1.3 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
3g 7
moo' D
cQ1 l
1.4 Water Supply (M.G.L. c. 40. S 54)
Publi Private
1.5 Flood Zone Information: Com t
Zone: BFE:
FWW ._
Section 2 - Property Ownership/Authorized Agent
g "� --i', u
2.1 Owner of Record: /�
Ma0,lC 41 Ir G[�A song _37S MA-5s L.v u ti
Nam ( Mailing Address
J<. /-663
Signature Telephone
uthorize t:
(�u•� A�V► UA—)
Nam rint) Mailing Addr
- W-r- NA-J . S m n
Signature Telephone
Section 3 - Construction Services
Licensed C truction Supervisor:
r F3
Not Appguj"gJ%A-�A1M0AJ
2 7Lice
oS
Expiration D e
Ad r _
Signature Telephone
3.2 Registered Home Improvement Contractor:
ompany Name
pI Vv1 cJ C C� S D �� Q t r
Not Applicable ❑
Licensember , ry
Addr
• ��p0 J ��
Signature Telephone
Expiration D e
S D
Lq-7 y
9- 15-99
1of2
OVER
Section 4 -Workers' Compensation Insurance Affidavit (M.G1_ c 1 �� G �sr. ra, �L
01
- . - -- -- -- - --... 1_'
Workers Compensatiln Insurance affidavit must be completed and submitted with this application. Failure `
to provide this affidavit will result in the denial f the issuance of the building permit.
Signed Affidavit Attached Yes .......... No ..........
Section 5 - Description of Proposed Work (check all applicable)
New Construction ❑ I No. of Bedrooms No. of Bathrooms
Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work: ,
4-,OA-) 4/
Section 6 - Estimated" Construction
Costs
Item
Estimated Cost (Dollars) to be
completed by permit applicant
Check Below
Conservation -Commission Filing
(if applicable)
Old Kings Highway & Historical
Commission approval
(if applicable)
1. Building
6 Ov•
2. Electrical
00
3. Plumbing / Gas
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5)
7op1J
7. Total Square Ft. (new houses & additions)
96
Section 7a - Owner Authorization -
Owner's'A ent or Contractor Applies
To be Completed When
for Building Permit
I, //24,2iOAJ 1��s& LeS n� , as owner of the subject property
hereby authorize n AVr' UPJ M A-fJ to act on
my behalf, in all matters relative to work authorized by this building permit application.
O�vt - k Ate- iS,�2ao/
Signature of Owner Date
Section 7b - Owner/Authorized Agent Declaration
�eqy % A �--��� t \ uy as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
�AV� ��A�YNu.tJ
name
J`
Sign of Owner/Agent Date
9-15-99
2of2
J.
03{oFYARic TOWN OF YARMOUTH
�r BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION SIGN OFF
Applicant��" �'`! Building Permit No.:
Address: S� �oti S� f'>�"' ; Tel. No.: 760 -'f/�JbDate Filed:
Bldg. Site Location: Y l f / A S C ` r , Map No.: Lot No.:
The following information outlines the procedural steps required to obtain a permit to build, alter, or add
to a structure within the Town of Yarmouth. The Building Department will determine compliance to the
following: (A) Zoning Requirements (B) Historical Districts (C) Flood Zones. The Building Department
will be responsible for assisting the applicant through the following departments:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT:
Determines Compliance of Water Availability. (applicant to obtain)
ENGINEERING DEPARTMENT:
Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION:
Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type
of Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc.
HEALTH DEPARTMENT:
Determines Compliance to State and Town Regulations; i.e., Requirements
for Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT:
Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
— — — — — — — — — — — — — — —
— — — — — — — — — — — — — — — — — — — — — — — — —
The following Departments must sign off, in the respective order, prior to building inspector issuing the required
building permit:
REV BY:
DATE: aC G b N/A:
WATER DEPARTMENT:
`
2. ENGINEERING DEPARTMENT: DATE: N/A:
i/ 3. CONSERVATION:
DATE: N/A:
V4. HEALTH DEPARTMENT
DATE: 2 % N/A:
INDUSTRIAL AND/OR COMMERCIAL PERMITS
5. WIRING INSPECTOR:
6. PLUMBING INSPECTOR:
7. FIRE DEPARTMENT: —
PLEASE NOTE
All stumps and/or brush must be disposed of at an approved site.
DATE:
DATE:
N/A:
N/A:
DATE:
N/A:
8/99 Applicant Signatur`' '-'��_' J---- Date
OF YAR.tr
32 �
�-.......may
PLEASE PRIA7.
Job Location:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
Vlna- �o� t-N cnorT
Number Street Village
Owner of Property: ���A H t 0.0 6 UA-) 6-7�f >
Construction Supervisor:-i9" ` �� ��" 0 _ �� V6
Name License No. Phone No.
S I Qa�� e- st-��N�:S y�� oD476
Address: S T co-
Licensed Designee:
(If other than Supervisor) Name
2.15 Responsibility of each license holder:
License No.
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Anylicenseewho shall willfully violate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
I have a current li insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes 4d No ❑
If you have checked yes, please indicat type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
er9—Owner
ass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature or Owner's Agent Owner ❑ Agent
Signature: Building Official Approval:
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the `reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work: O.y Est. Cost? ooc-)
Address of Work /%
Owner Name:
Date of Permit Application: / /3d l0
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury:
I here y 7opl
ly for a�permit as the agent of the owner:
3v `1DS717
Date Contractor Name Registration No.
•A
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
Date
Owner Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
exce011" stlpsthis
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
u11j
cit% \, Al^ fHaeri/-(poVT- phone# --76o-,S?Y6
I aria homeowner performing all work myself.
I am a sole proprietor and ha%e no one working in any capacity
I am an employerpro% iding workers' compensation for my employees working on this job.
Le> - S-r- ti'.
—S)e1G
insurance co 6,F1 A,j s tG S'tA�Y N s• policy # W e O % / —'66— / 7
r7 I am a sole proprietor. general contractor, or homeowner (circle one) and have hired the contractors listed below who ha%e
the follo%%in_ %%orkers' compensation polices:
company name:
city.phone #-
insurance co policy #
company name:
Failure to secure coverage as required under Section 25A of MGL 152 an lead to the imposition of erimiaal penalties of a line op to $1,5N.09 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Iide of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DU for coverage verification.
l doh y c ' • u t r and penalties of perjury that the information provided above is true and co em
Signature ��� Date 3o a
Print name J_J A� Z�/�� ►t+`�^J Phone# 76a ��1 �b
I
fficial use only do not write in this area to be completed by city or town 0111eial
city or town: YARMOUTI1
o check if immediate response is required
contact person:
permitlliccnse # aBuilding Department
Licensing Board
261 ❑Selectmen's Office
Health Department
phone #; _ (508) 398-2231 ext. n0ther
(rn oed 3,05 P) A 1
Information and Instructions
Massachusetts General Lays chapter 152 section 25 requires all employers to provide workers' compensation for their
employ ees. As quoted from the "law", an enrplot•ee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An emtploYer is defined as an indi% idual, partnership, association. corporation or other legal entity, or any two or more of
the foreaoin: 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
o%%ner of a d%kellin_ house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another %%ho employs persons to do maintenance , construction or repair work on such dwelling house
or on the urounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
%1GL chapter 152 section 2� also states that even- 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. neither the commomyealth nor any of its political subdivisions shall enter into any contract for the
performance of public y\ork until acceptable evidence of compliance with the insurance requirements of this chapter hay e
been presented to the contracting authority.
Applicants
Please till in the workers' compensation affidavit completely. by checking the box that applies to your situation and
supplying company names. address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affiday it 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 %%orkers' compensation policy, please call the Department at the number listed below.
City or Towns
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. The affdavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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 lares1112deles
600 Washington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 7274900 exL 406, 409 or 375
TOWN OF YARMOUTH
1146ROUTE28 SOUTHYARMOUTH MASSACHUSETTS02664-4451
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at -ell G j rG I z—
Work Address l
is to be disposed of at the following location: J-0 0 u
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Applicant Date
Permit No.
PLOT PLAN
AbuttorIs
Name
Lot #
If this is a
corner lot,
write in name
of street.
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines --------------------
Sewerage disposal (cesspool)
Well 0
SIDE YARD
- - FT=
(lot................ft. rear)
4
REAR YARD
.............ft.
HOUSE
Q
SET BACK
SIDE YARD
0-----FT,>
(lot..................ft. frontage)
(NAME OF STREET)
Information
Supplied by
Abuttor I s
Name
Lot #
If this is
corner lo-
write in
name of
other
street.
b
MARK NORTH POINT
It,
,00
LoTZ�
•ao
n �
4
4rzc# _
9-9/000 5 F=
qy ti
hv
SRO QF �
TO THE BEST OF MY INFORMATION,.
KNOWLEDGE, AND BELIEF THE
ST/zaerL,rzd' SHOWN.. ON THIS
PLAN HAS BEEN LOCATED O,N :,.THE
GROUND AS INDICATED<`:•
DATE PROFESSIONAL LAMP,) :UEYO
"AS -BUILT" PLOT PLAN
YARMO�UTH,. MASS.
�� EL L1,5' C / 44r
DATE ZOc/ SCALE /"=30'
JOB CLIENT Gi r4.roj
SWEETSER ENGINEERING
235 GREAT WESTERN ROAD
P.O. BOX 713
SOUTH DENNIS, MASS.
398-3922 02660 FAX 398-3063
• • 6241
Old King's Highway Regional Historic District Committee
in the Town of Yarmouth for a
CERTIFICATE OF APPROPRIATENESS
Application is hereby made in triplicate, for the issuance of a Certificate of Appropriateness under Section 6
of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on
plans, drawings or photographs accompanying this application for:
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction: ❑ New Building b Addition ❑ Alteration
Indicate type of building: ❑ House ❑ Garage ❑ Commercial ❑ Other
77TV E D
2. Exterior Painting: ❑
3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting existing sign 00 r1UL 27 an 9.41
A..^
4. Stnutum: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other 7n . " rn LAZ• uRER
S�uTH `r'iu:i;uUTli '' IJIA
TYPE OR PRINT LEGIBLY DATE 7 / 6 /OO
ADDRESS OF PROPOSED WORK 41 Ellis Circ ASSESSORS MAP NO. 133
OWNER Marion Gleason ASSESSORS LOT NO.23
HOME -ADDRESS 385 Mass Av Arlington Ma 02474 TELEPHONE NO. 79 —6] 41-0634
AGENT OR CONTRACTOR Claude Cor ; v a r _TELEPHONE N0362-2639
ADDRESS P•O.Box 284 Yarmouth Port Ma 02675
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERS
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particula[S.o(�%prk to be done including materials to
be used. In case of signs. give locations o1 existing signs and proposed locations of new signs. (Attach additional'sh-dA if
naxssan).
APPROVED
YARMOUTH COMMITTEE f ��
OKHRD
Signed llz-,�4-ivkl .+s
(htiner-Contractor-Agent
Space below line for Committee ase onh•.
Received by OKHC
Datc �/ �� �� Thi e ificate is he Dale
Check #
By ,
APPROVED ❑ EWPORTANT: ICCertiticate is approved. approval is subject to the 10 day appeal period
provided in the Act.
DISAPPROVED ❑ Please return to: Yarmouth OKIIC District Committee
Yarmouth Town Hall, 1146 Route 28, S. Yarmouth, MA 02664
TOWN OF YARMOUTH
BOARD OF APPEALS
DECISION
FILED WITH TOWN CLERK:
PETITION NO: #3640
October 11, 2000
HEARING DATE: September 28, 2000
PETITIONER: Marion Gleason
y/, F11 0I ITH
7® OCT 1 1 PH 1: 43
RECE-NED
PROPERTY: 41 Ellis Circle, Yarmouthport
Map: 133, Parcel: 23 (119/A25) Zoning District: R40
MEMBERS PRESENT AND VOTING: David Reid, Chairman, James Robertson, Joseph
Sarnosky, Diane Moudouris, John Richards, Robert Reid, Alternate.
It appearing that notice of said hearing has been given by sending notice thereof to the petitioner and all
those owners of property deemed by the Board to be affected thereby, and to the public by posting notice
of the hearing and published in The Register, the hearing was opened and held on the date stated above.
The petitioner proposes to demolish an existing deck and replace it with a one story three (3)
season porch. As the structure would extend to within 17' of the property's rear lot line, where
20' is required in the R40 zone, a Special Permit was requested.
The petitioner represented that the proposed design and location has received the approval of the
Old Kings Highway Committee and the Conservation Commission. The existing deck is
apparently built without the benefit of any building permit. The proposed enclosed porch would
not be heated but would be enclosed to the weather.
Neighbors objected to the proposed expansion of the small home. Board members observed that
the petitioner had several other solutions apparently available to them, including relocating the
porch or simply reducing its size to meet the 20' setback which would apparently not require any
relief.
The petitioner requested leave to withdraw the request for the Special Permit. Mr. Robertson
made a motion to allow the petition to be withdrawn with out prejudice. Mr. Richards seconded
the motion which passed unanimously in favor.
David S. Reid, Clerk
-1-
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
TOWN OF YARMOUTH
(OFFICE USE ONLY)
Fee: o �
PERMIT NO. E-ol ^ O /
2(O
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 'r " `"
To the Inspector of Wires: By this appl c.�ation the undersigned gives notice of his or her intention to perform the electrical
work described below. 36
Location (Street & Number) /1 f LEI L 1 S C/ N C J- t=
Owner or Tenant H -,1 t- o tq _ I e- C [ / I /, Telephone No.
Owner's Address 'S 3 5S r'L S s Ave rrH--��y��� t v� t l"
Is this permit in conjunction with a building permit? 1�1'Yes Q No (Check Appropriate Box)
Purpose of Building S,nc lc -fdnJI44 we/�in e- Utility Authorization No
Undgrd ❑
Existing Service /aU Amps 3 / / �2 o Volts
New Service Amps / Volts
OverheadQ_o_�
Overhead
No. of Meters /
Undgrd 0 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed electrical Work: it / / Y / I & o . fit ic/<�.
Conmletian of the fallotrine table tnav be waived by the Inspector of Wires
No. of Total
No. of Recessed Fixtures
No. of Ceil.-Sus Paddle Fans
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
Above In- Fj
No. of Emergency Lighting
No. of Lighting Fixtures
Swimming Pool -rnd. gornd.
Battery Units
No. of Receptacle Outlets (o
No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
Number
— —
Tons
—
KW_
No. of Self -Contained
No. of Waste Disposers
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Municipal Other
Local Connection
No. of Dryers
Heating Appliances KW
Secutity Systems:
No. of Devices or Equipvalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of i5evices or Equivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
Attach additional detail if desired, or as requtrea oy the inspector of Mies.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may be issued unless the licensee provides
proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies t at such coverage is in
force, and has exhibited proof of same to permit issuing office.
CHECK ONE: INSURANCE BOND OTHER (Specify:) ? `�U l0 Z
(Expiration Date)
Estimated Value of Electrical Work: Aile001 Gd (When required by municipal policy.)
Work to Start: o Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under tlh, pains and penalt)ies of perjury, that the information on this application is true and complete.
FIRM NAME: V1 1 1 1 �-!� LIC. NO. i� / S- 7 �2 U
Licensee: jc• \ t \� Iasi Ic Signature _ r�A G LIC. NO. �s7� Cl
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: /-(,. /?— 311— -73 9/
Address-=1-7 L)7ikI S4, 82T.n/1 LUZtrt4e,UrL, (v%7� rRY?,L All. Tel. No.:/-Co/7 79V- %A19
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature
below, I hereby waive this requirement. I am the (check one) owner U% owner's agent. � / 7Y/ � � Fj7 _ G 6 � t_/
Owner/Agent
Signature `�IC/(tLtr. y�tlty+✓ Telephone No. /—SUS �G —557 /
[Rev. 04/001
Appeal #3677
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BOARD OF APPEALS
Date: April 11, 2001
Certificate of Granting of a Special Permit
(General Laws Chapter 40A, Section 11)
The Board of Appeals of the Town of Yarmouth Massachusetts hereby certifies that a
C1 Special Permit has been granted
To: Simon's Supply Company, Inc.
Address: 586 Higgins Crowell Road
City or Town: West Yarmouth, MA 02673
o affecting the rights of the owner with respect to land or buildings at: 586 Higgins Crowell Road,
West Yarmouth, MA. Assessor's Map: 84, Parcel: 3, (64/E8) Zoning District:113
V�
and the said Board of Appeals further certifies that the decision attached hereto is a true and correct
kL copy of its decision granting said Special Permit, and that copies of said decision, and of all plans
j� referred to in the decision, have been filed with the Planning Board and the Town Clerk.
�
The Board of Appeals also calls to the attention of the owner or Pp applicant that General Laws,
Chapter 40A, Section 11 (last paragraph) and Section 13, provides that no Special Pemrit, or any
extension, modification or renewal thereof, shall take effect until a copy of the decision bearing the
certification of the Town Clerk that twenty (20) days have elapsed after the decision has been filed
in the office of the Town Clerk and no appeal has been filed or that, if such appeal has been filed,
�Y that it has been dismissed or denied, is recorded in the registry of deeds for the county and district
in which the land is located and indexed in the grantor index under the name of the owner of record
or is recorded and noted on the owner's certificate of title. The fee for such recording or registering
shall be paid by the owner or applicant.
22
David S. Reid, Clerk
CERTIFICATE-S.P#3677. WPD
TOWN OF YARMOUTH
BOARD OF APPEALS
DECISION
FILED WITH TOWN CLERK:
PETITION NO: #3640
October 11, 2000
HEARING DATE: September 28, 2000
PETITIONER: Marion Gleason
Yk RM01.�TH
2QB OCT 1 I PH 1: u 3
RECELIVED
PROPERTY: 41 Ellis Circle, Yarmouthport
Map: 133, Parcel: 23 (119/A25) Zoning District: R40
MEMBERS PRESENT AND VOTING: David Reid, Chairman, James Robertson, Joseph
Sarnosky, Diane Moudouris, John Richards, Robert Reid, Alternate.
It appearing that notice of said hearing has been given by sending notice thereof to the petitioner and all
those owners of property deemed by the Board to be affected thereby, and to the public by posting notice
of the hearing and published in The Register, the hearing was opened and held on the date stated above.
The petitioner proposes to demolish an existing deck and replace it with a one story three (3)
season porch. As the structure would extend to within 17' of the property's rear lot line, where
20' is required in the R40 zone, a Special Permit was requested.
The petitioner represented that the proposed design and location has received the approval of the
Old Kings Highway Committee and the Conservation Commission. The existing deck is
apparently built without the benefit of any building permit. The proposed enclosed porch would
not be heated but would be enclosed to the weather.
Neighbors objected to the proposed expansion of the small home. Board members observed that
the petitioner had several other solutions apparently available to them, including relocating the
porch or simply reducing its size to meet the 20' setback which would apparently not require any
relief.
The petitioner requested leave to withdraw the request for the Special Permit. Mr. Robertson
made a motion to allow the petition to be withdrawn with out prejudice. Mr. Richards seconded
the motion which passed unanimously in favor.
David S. Reid, Clerk
TOWN OF YARMOUTH
BOARD OF APPEALS
APPLICATION FOR HEARING
Appeal #: U Hearing Date: Fee$ 1 Q
Applicant:
111.RR I c A,
lee AUG 23 Pm 1:25
(Full Name- including d/b/a)
Lig0C, !� me f i,5/I%, SS alz
(Address) J (zip) (Telephone Number) /- %P1-6 ql
and is the (check one) Owner ❑ Tenant ❑ Prospective Buyer ❑ Other Interested Party
Property: This application relates to the property located at:a/ 'elmclack
Yin— which is alsp shown on the new Assessor's Map: /• 3 3 _ as Parcel: —A r _(old Map & Lot #) Zoning District: ;e _ yd
Project: The applicant seeks permission to undertake the following construction/use/activity :(give a brief
description of the project. i.e.: "add a 10' by 15' deck to the front of our house" or "change the use of the existing
building on the property"): If� •-MQ, g-xzLar PLC.% 7a _
RELIEF REQUESTED: The applicant seeks the following relief from the Board of Appeals:
1) REVERSE THE DECISION OF THE BUILDING INSPECTOR OR THE ZONING
ADMINISTRATOR dated (attach a copy of the decision appealed from). State the reason for
reversal and the ruling which you request the Board to make.
2) SPECIAL PERMIT under § JC2 2, 3 3 4ze�£ of the Yarmouth Zoning By-law and/or for a use
authorized upon Special Permit in the "Use Regulation n Schedule" §202.5
3) VARIANCE from the Yarmouth Zoning By-law. Specify all sections of the by-law from which relief is
requested, and, as to each section. specify, the relief sought:
Section:
Relief sought:
Section:
Relief sought:
Section:
Relief sought:
Additional comments:
FACT SHEET
This sheet must be completed and filed at the time of application.
Owner of Property (if other than applicant) S1 M
(Full Name)
( Address) - (Telephone Number)
How long has the owner had title to the above premises: v - W-,V 1 g , 10as'
(Give title reference if available)
Use Classification: Existing:. ZA,, 5 LQ §202.5 # r?
Proposed:
Is the property vacant: 4U C How long has it been vacant:
Lot Information (if available) Area: i ate} c�c1, ; Subdivision/Plan Reference: /
Is this property within the Aquifer Protection Overlay District: Yes No ✓
Other Department(s) Reviewing Project: Indicate the other Town Departments which are/ have/ or will review
this project, and indicate the status of their review process:
Repetitive Petition: Is this a re -application: If yes, do you have Planning Board Approval:
Prior Relief: If the property in question has been the subject of prior application to the Board of Appeals or Zoning
Administrator, indicate the Appeal number(s) and other available information:
/Uoh E
ADDITIONAL INFORMATION: Please use the space below to provide any additional information which you
feel should be included in your application:
Applicant's Signature/Attorney Address
ding Inspector's Signature
Owner's Signature
Site Plan Review
Required Completed
❑ Yes ❑ No 0 Yes 0 No
0 AUG 23 am . 1=2
24.3' LOT 25 ; i
A- - SILOT A251 �y ,
0• cP�
:Cn . 4.0' i 6�
CB
.dL AL
AL
�0
RES. ZONE- "R40" This MORTGAGE INSPECTION Plan is For Bank ZONE.• 7Bank Use On]
TOWN: _XARMQZITHP,----------- REGISTRY OWNER: Q�1N_- ------------------
DEED REF: -1424 _429______------BUYER: _jVA&0ff Kj2LEASJZY--------------------------
DATE: _Z1241m---------------- PLAN REF: _15�151 &_D ---- SCALE:1"= 40 --- FT.
I HEREBY CERTIFY TO BQFTQAL�N Of v YANKEE SURVEY
SA ITINGS BANK THAT THE BUILDING
�� ���,
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS PA CONSULTANTS = A
SHOWN AND THAT ITS POSITION DOES CONFORM MERrMEtiV H 40B (SUITE i)
TO THE ZONING LAW SETBACK REQUIREMENTS OF THE No.32o9e Q INDUSTRY ROAD
TOWN OF —�'QR UZj� —AND THAT
IT DOES NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD sTI MARSTONS MILLS, MA. 02648
AREA AS SHOWN ON THE H.U.D..MAP DATED_%fZS_22_ �O�AI <�Nos°� TEL 428-0055
Community— Panel # 250015 0001 D FAX 420-5553
THIS PLAN NOT MADE FROM AN INSTRUMENT 24483 DCB
pAUC-A: 1� tZ7 W-lsf- — crravry Nnm Tn AR USED FOR FENCES. FTC
^,
,
29
(1191
32
.51 AC
tu
cc
YAMAFOUYYI
33
(I ON5Z
-36
AC
39
40
*78 AC
42
631
AC
IAC