HomeMy WebLinkAboutBuilding Permits (5)F Yq BUILDING PERMiT.AIPPLICATiON
t c. ICATION MCONSTRUCT, REPAIR,,RENOVATE ,CHANGE THE 'USE- 66t..UF/1f
EMOLISH ANY BUILDING o "E THAN,A ONE O,R TWO,'FAMILY DWELLING + ;
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Section i Site ormation,
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Zornng, District Proposed Use
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Rear Yard
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corhOWe St. S60brif. if exitWigbuildinj Unoistooft. renovations: -additions and/or , ifili b �hange W.
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Exisfinq,H, p#rd Index 78Q,��PMR. 14
Proposed Hazard Index 780 CMR 34,
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass:gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anulicant Information n Please Print Legibly
Name (Business/Organization/Individoai): V9tT1r uZ�-�a u5}�S
Address: ,Q. p . $ ox 3 LIg
Ci /State/Zi : TA,- -ma
A- G 5' Phone #:
- 9V -C -1(0
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
6. ❑New construction
employees (full and/or part-time).*
have hired the sub -contractors
2. 01-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
required:]
comp. insurance.:
ur
5. ❑ We are a corporation and its
10.0 Electrical repairs or additions
3. ❑ I am a homeowner doingall work
officers have exercised their
I I . Plumb,in
❑ g repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12. Roof airs
❑
insurance, required,] t
❑
c. 152, § 1(4), and we have no
13.❑ Other
3a. I am a homeowner acting as a
employees. [No workers'
general contractor (refer to #4)
como. insurance required.l
*Any applicant that checks box #1 must also fill out the section below showing their workers' conrpeosatiodlsoiicy 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.
Ian an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:_ 01)0& J o+1.0dyL_
Policy # or Self -ins. Lie. #:.
Expiration Date:
Job Site Address: City/Statetzip:
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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK -ORDER and a fine
of up to S250.00 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 curb# un#r t ie pains and penalties of perjury that the information provided above is true and correct
Qffleial use only. Do not write in this area, to be completed by city or town official
CIty or Town: Permit/LIcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
Information and Instructions i
k•
b
Mm uchusetts General Laws chapter 152 rtquira all employ>srs to provide worimrs, compensation foa their enspjoyea.
pursuu t to this statutes as emVkyee is defined as "...every person is the service of another undo any contract of hire,
express at implied, oral or written."
An xplarr is defined at "era inidua divl, ParmerW* usocnatnoa, corps sd= of other k entity
a, or my two a mores
of tits fofegoiag mpg in a joist � �� � � � of a deterred empbM at tits
Mceiver of ti _ter of a. iwiridtd. pettoasi>* umciatke or otbw IeW entity, empioyiag COPbl^& However the
owner of a dwelling Icrase having not mots d= thta spartmeca ad who asides thaea, of t5t ooatnpant of -fie
dwelling boast of aaothst who eagbys persons to do mainumme, const<et dM or repair work on such dwelling hours
or on tits p ob or building apPor'ten'ult thereto shall not because of sock eapkyment be deemed to be in employe:»"
N4GL chapter 1S2,12SC(6)also states that "every stater er kcal iketsdag ageaey sisit withheld the lssaasas Of
m4wwsd ei a Heente ere pwmk to operate a bataass or to eenMrud bWdiap In the esmtnnatth fie Uq
spplkant wbo hr not proioeed seeepb bb erldeaes of eempH-aee with the lawyers" anrap r"Eko L"
AddWondly, MGL cbspber 1A 12Si7) subw "Neuters the commoaweaith not ANY of its political subdivision- shall
caber ism my ca m&ad for the pcd misses of public wotk to W aceeptabb evidence of eompiinas with tfw iaaaaace
requkemeds of this cbq*w have been presented to the eouttacting aathor>h►."
APPuma
Please iQ out the wvcbu, compensation afAdavit comptddy, by checking the boxes that apply to yoat situation and, if
necesas:y, supply toes) news(s). add ,*cs) and pbow nambea(s) along with their catifleaa(s) of
insamn= Limited Liability Companies (LLG7 a Limited Liability PumushVe (LLP) with no aWbyves other titers the
members or pwuma• an not mquited to emy warlons' compensation iaraaacs: If as LLC or LLP does haw
ca4bya% a policy is reqind Be advised that this affidavit map be subusitted to the Depufta t of Indu $Wd
Acculamb At boa of iasiaancs coversga: Abe be scare to sip and dab the affidavit. The affidavit should
be r-A n, ed to the city or tows that the application tint the se
permit a license is being requested set the Deperomed of
Ind=UW Accideda, Sbould you hams any I 1 11ooa 1 0 1;og the lays a if you an ceq dad to obtain a wort eW
conqPeaation poBcA plane calltht Depert oo t at the member listed bekw. Sdf-insured conV is sbmM eater their
self-iowat aset Iicenm nermber on the appropriate lint.
City or Tom Ofelait
Please be sacs that this affidavit is complete and printed legibly. 'tie Depubne t has provided a space at the bottom
of the a8idavit for you to a out in this event the Office of Investigsdons here to coated you regarding tbt applicant
Pleasis be setre to fM is the perm>Nitxase umber which will be used as a mference muster. In addition, se applicant
that scent wAnit muldPM perms applications in any given year, need only submit one affidavit hmHcatiag eemy' eot
policy Wit motion (if mccomy) sad =kv "Job She A&k=C the applicant simM writs "all locadoo- in (criy or
tb mV A copy of the affidavit Chet het been officially somped or madad by the city or tows may be provided to the
applicad at prod that a vsM af6dwk is on Sir Aw Abu pumb of liceoms. A now affidavit cant be filled Ott each
yeas. Whore a bon owner at citizen is obtaining a license or permit not related to say business of coaamacW venptts
(i.e. a dog Sceme of permit to burn Item ere.) said person is NOT requited to coagkte this afidsvit.
The O@fa of lavestipdoat would Me'to thank you in advaoce far your cooperation and should you haw sap question-,
pleas- do not haitme to give m a aLL
rho Depumsrnt's addm a. to lephow and fors number:
Tlx Commonwealth of Massachusetts
Department of Indnstcial Accidents
Of&* of lay"dPda"
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-977-MASSAR
Fax # 617-727-7749
Revised 11-224A6 www,mass_pv/dia
'13x°4YARc TOWN OF YARMOUTH
0
r{• F�;,y BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PPJNT.•
Job Location: Q-77 SIn-Ore T-r ShJ
Number Street Village
Owner of Property: —ML a Sa,, S LG
Construction Supervisor:
Name
CS- 08
License No.
Address: P 0 , 15fl)t 31114 `/ rhu,.? f Pam{- , Mgt' 7S'—
Licensed Designee:
(If other than Supervisor)
Name
2.15 Responsibility of each license holder:
License No.
es�Lfl3
Is
•
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 Any licensee who shall willfullyviolate 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 liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes Ca— No ❑
If you have checked M, 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 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of 6wner or Owners Agent Owner ❑ Agent
Signature: Building Official Approval:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, NIA 02664
508-398-2231 ext.1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
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 ,2 77
Work Address
Is to be disposed of at the following location: S j T sxca
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signatur of Application
Permit No.
Date
y. Massachusetts - Department of Public Safety
Board of Building Regulations and Standards.
Construction Supervisor
License: CS-081040
PATRICK H JACOBS .
28 WYHTTIER DR a
DFAINTIS MA 02638
Expiration .
Commissioner 04104MO d
24Q, Office of Consumer AfPairs�& u�sin Regulation
fi ME IMPROVEMENT CONTRACTOR
istration: 165888 Type:
Oration: 4/WG16 DBA ;
=? R JAC BS CUSTOM CARPENTRY &REMODELING
' PATRICK JACOBS
28 WH{iTER DR.
DENNIS, MA 02638
' Undersecretary
'.e�
Sur f Sand
on Nantucket Sound
... • of of • of .
November 30, 2015
Town of Yarmouth
Building Department
To Whom It May Concern:
This is to inform you that Pat Jacobs will be doing the work at the Surf & Sand Motel, located at 277
South Shore Drive, South Yarmouth, MA.
Thank you.
Best Regards,
Sandra M. DiGiovanni
Manager
277 South Shore Drive
So. Yarmouth, MA 02664
508-398-3700
MGL AND FIRE:
TOWN OF Y(ARMOUTH
REVIEWED FOR CODE COMPLIANCE.
ERRORS OR OMMISSIONS DO NOT RELIEVE
THE APPLICANT FROM THE RESPONSIBILITY
OF "AS BUILT" C MPLIANCE.
DATE:%!x
INSP TOR
YARMOUTH FIRE PREVENTION
Commercial Construction Building Transmittal
Project Name: Surf and Sand
Shore Dr
Contact Name: Pat Jacobs
Address:277 South
Phone: 508-694-6406
Y NO NA Subject Regulation
E
S
x
Access for Fire Apparatus
527 CMR 1; 18.2.4.1
x
Building Numbers
MGL Chapter 148; sec 59
x
*Flammable gas/liquid storage
527 CMR 1; 42.2.2.1
x
Fire Lanes
527 CMR 1; 22.3
x
*Service Stations
527 CMR 1 ;16.2.3,16.2.3.1,30.3.2
x
*Hazardous Materials Storage
527 CMR 1; 60.1
x
*Kitchen Exhaust Systems*
780 CMR, 527 1; 50.1
x
Extinguishers
527 CMR 1; 13.6, Chapter 148; sec 28
x
Fire Alarm Systems/CO detection *
780 CMR, Chapter 148;, 527 CMR 1; 13.7
x
*LPG Storage
Chapter 148; sec 9,10,28 & 527 CMR 1; 69.1
x
Use and Occupancy ( FH Building Class)
780 CMR; 302.1
x
Sprinkler Systems *
780 CMR & Chapter 148 sec 26 A -I
x
Storage inside/outside Buildings
527 CMR 1; 10.19.4, 4.4.3.1.1,19.1.2,34.1.1
x
*Upholstery
527 CMR 1; 20.6.2.5
x
*Trash Containers
527 CMR 1; 19.1.1, 1.12
x
Any Hazard to the Public
Chapter 148; sec 28
x
I *Curtains, Draperies, Blinds
527 CMR 1; 12.6.2
* YFD permit required -depending on occupancy and submittal
*Per 780 CMR 901.5, contact Yarmouth Fire Department for acceptance test.
Description of planned project/other requirements: Renovation three rooms 109,209,207.
Maintain any fire protection system.
Plan Reviewed By: Captain/Inspector r (1wotwag
Copy for Applicant = Copy to Building Depart nt 0
Entered in Firehouse =
Date: 1 ' 13 1 /Cf,
Copy to Fire Prevention 0
Final Inspection 0
, = TOWN OF YARMOUTH
° HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location:
SU r F Q 5Cr
V V% j x$
Proposed Improvement: ( iC. L2� °te a >Q 0 7
Applicant: e,d 7 Ci c c� b S Tel. No.: Jo r 6 5 q p la X
Address: Date Filed: /
**Ifyou would like e-mail notification ofsign off, please provide e-mail address:
Owner Name: Su c P c h j "yd4p
Owner Address: �� �% sLf Owner Tel. No.:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: DATE:
PLEASE NOTE
COMMENTS/CONDITIONS :
40,
2/4/2016 SlipGen- Portal Home
y Town of Yarmouth
■
Template [Building Dept]
y
Slipsheet Identifier [sg39387]
Document Category Building Permits
Map -Block Number 026.127
Street Number
0277
Street Name
SOUTH SHORE DR
Department
Building
Parcel ID
3333
Backfile Batch Scan
No
Document?
Additional Naming Info
Index Operator
Operator, Yarmscan
Date - Time
2016-02-04 - 08:55
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