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HomeMy WebLinkAboutBLD-15-2887O y "ATTACK 5 fa�r„p�, BUILDING PERMIT APPLICATION APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. Toivn of Yarmouth Building. Department 1146 Route 28 • l arrnouth. NfA 02664-4.192 Tel: 50&398-2231 eXL 1261 Fax 508-398-0836 PeA�j�� `Office Use Only Planning Board Information Assessors Department Information: lt'No. `J —qq; ,c� ✓f Plan Type M tot Permit Fee $ ����,pa! Endorsement Date/ /�'b Recording Date New Deposit Rec'd. $ Date Plan No. 1.4 Property Dimensions: Net Due $ Other Lot Area (sf) Frontage (f) Lot Coverage This Section for Office Use Only Building Pe ' umbe . Date Issued: Signature:21 Building Officiai Date- Certificate of Occupancy. is Is not required Section 1 - Site Information 1.1 Propirty Address: 1.2 Zoning Information: yyaG rr Zoning District Proposed Use 1.3 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required I Provided Required I Provided Required I Provided 1.4 Water Supply (t (ILL. o. 40.3 541 1.5 Flood Zone Mformaftm Comments: Public Prival I Zone: BFE: Section 2 - F 2.1 Oar of A 2.2 Authorized Hants (paint( Telephone Signature Telephone Mailing Address: SO&- ?�qB— Telephone Mailing Address: Fax Email Address: Email Address: Section 3 - Construction Services 3.1 L 11comod Constriction Supervisor: Not Applicable I] License Number -5 tom` 044- 0�23 G3-a Address 7$(Expiration Date Signature UTelephone Email Address: Go* 3/ /31ib 1 of 4 OVER 3.2 Registered Home Improvement Contractor. Company Name Not Applicable (� �} � ` �� "' Registration Number Address 4' r P G i Expiration Date Signatu Telephone 6 Section 4 - Workers' Compensation Insurance Affidavit (MAL c.152 S 25C Workers Compensation insurance affidavit must be completed and submitt with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin ermit_ Signed Affidavit Attached Yes .......... No .......... Section 5 - Professional Design and Construction Services - for Buildings Structures Subject to Constriction Control Pursuant to 780 CMR 116 (containing more than c.f. of enclosed space) Section .I Registered Architect: Not AppNpble ❑ NamS ( strand: t �f �Gs�•�-? ` g R lion Number 9ro2o Address Gam Expiration Data Signature Telephone Section 5.2 Registered Professional Engineers) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date ame N. Area of Responsb" Address Registration Number Signature Telephone Lion Date Name rea of-Responsiblitty Address egWttration Number Signature Telephone xpiration Date Name me of Responsibl" . Address Number aatiobn Signature Telephone ate Section 5.3 General Contractor Company Name Person Responsible for Construction Address Applicable, El Signature Telephone .4P 2 of 4 Section 6 - Descriptign of Proposed Work (check ail applicable) New Construction (for multiple family only) No. of Bedrooms (for multiple family only) No. of Bathrooms Existing Bldg. ❑ Repalr(s) ❑ Alterations ❑ I Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: Brief Description of Proposed Work: Section 7 - Use Group and Construction Type Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A.1 ❑ A-2 ❑ A-4 ❑ A-5 ❑ A-3 ❑ 1A ❑ 1 B ❑ B BUSINESS ❑ 2A ❑ 28 ❑ 2C ❑ E EDUCATIONAL ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ H HIGH HAZARD ❑ 3A ❑ 3B ❑ I INSTITUTIONAL ❑ 1-i ❑ 1-2 ❑ 1-3 ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ 5B ❑ S STORAGE ❑ S-1 ❑ S-2 ❑ U UTILITY ❑ SPECIFY: SPECIFY: SPECIFY: M MIXED USE ❑ S SPECIAL USE ❑ Complete this section if existing building undergoing. renovations: additions and/or change in use. Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed Hazard Index 780 CMR 34 Section 8 Building Heigh and Area Building Area Existing (if applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor (sf) Total Area All Floors (sf) Total Height (ft) Section 9 - STRUCTURAL PEER REVIEW (780CMR 11011) Independent Structural Engineering Structural Peer Review Required Yes .......... No .......... SECTION 10a OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNMS AGENT OR CONTRACTOR APPLIES FOR B ING PERMIT as Owner of the subject propen hereby authorize Cv� `"� t�G to act on my behalf, i lative to a zed by this building permit appiica 'on. I /-?, / I / re of Owner Date 3 of 4 OVER SECTION 10b OWNER/ AUTHORIZED AGENT DECLARATION I, P$�/ hereby declare that the statements and information on the forgoing appl the best of rry knowledge and belief. Signed under the pains and penalties of perjury. Print Of Section 11 - ESTIMATED CO UCTION COSTS Item Estimated Cost (Dollars) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing / Gas 4. Mechanical (HVAC) S. Fire Protection 6.Total=(1+2+3+4+5) 7. Total Square FL (br nm Drumm a ad3maw Check Below ❑ Conservation -Commission Fling (if applicable) ❑ Old Kings Highway & Historical Commission approval (if applicable) �- ner/Authorized Agent are true and_acurate; to. f Z�/ Date in 4of4 - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street K Boston, MA 02111 www.mas&govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print Legibly Name(Business/Organizationandividtw): Address: L< ��c= �y �' 1b&R7 'Jo01J ) 1/14/4— 4f 1,?2 .4 1 Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. E�l am a employer with - 0 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have Lured the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insuranCe comp. insurance.t 9. (] Building addition required:] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doingall work officers have exercised their 11. Plumbin ❑ g 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 13.❑Other 3a. I am a homeowner acting as a employees. [No workers' general contractor (rem to #-4) comp, insurance required.] ,Amy applicant that checks box #1 must also fill out the section below showing their wod=e compensaticd Ooluy inkm ation. nomeaw n= wno suomn sus amdavtt mmcauag Macy are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContactora that check this box must attached an additional shed showing the name of the aab-contractors and state whether or not those entities have employees. If the sub-contactots have employees, they must provide their workers' comp. policy number; lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site informadom Insurance Company Name:.Gl? Policy # or Self -ins. Lie. #: Expiration Date: 14� 2?�5• 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 $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ccreif j+ under the p raid penalties of perjury that the informadon provided above is true and correct Sign Date: Pima k- Offleial use only. Do not write in this area, to be completed by city or town of eiaL CIty or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: `Y PLEASE PRINT. - Job Location: TOWN OF YARMOUTH BUILDING DEPARTMENT CONSTRUCTION. SUPERVISOR FORM Number Owner of Property: Construction Supervisor: Name Street 6) - (zrw, G --3, --- 0 License No. Village Address: z0—'57$ Licensed Designee: (If other than Supervisor) Name 2.15 Responsibility of each license holder: License No. Phone 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 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 revocadon 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 tinder 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 ❑ 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 Owner or Owner's Agent Owner d Agent ❑ Signature: Building Official Approval: O H TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28, South Yarmouth,lViA 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 -0 z�--OY14-:5? Work Address Is to be disposed of at the following location: --7?? ✓W '-'&A/i Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Appli ation Permit No. �1 Lw Date r.l QA lJJ-1 i J VJ 4wiZ V+ zv. ws saa + as..a. ...• v�.r + v++ vv� + v� f`' CERTIFICATE OF LIABIUTY INSURANCE I °A (zmp"I't (U7A1Rl7111d WITIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS IIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATM TTANT: If the cordrmM holder Is an ADDITIONAL INSURED, the pollcy(ies) amst be endorsed. If SUBROGATION IS WAIVED, subject to the and conditions of the policy, certain policies may require and endorsm*nL A statanent on this certUicaie does not confer rights to the PRODUCER HANSON INSURANCE AGENCY 632 COUNTY RD HANSON, MA 02341 28X6B INSURED DANDEL CONSTRUCTION INC PHONE PAX (AIC, Hlo, E>* (AIC, No): E-MAIL ADDRESS: INSURER(S)AMRONG COVERAGE BMUiERA: AMERVANTARIQiIIISURANCECOMPANY NAIL# INSURER D. 1 LIBERTY STREET INSURER E. HANSON, MA 02341 ItASURER F. COVERAGES CERTrK ATE NUMBER: REVISION NUMBER: aaalR�nllr®ABOYEFURTIEPOLICYPEINODNOCATEM NOTYRFMTANOW ANY REQIIa�tr,TM OR COMMON OF ANYCONTRACr OR OTIM DOCIaaalr WIM RESPECTTO trMCH TNRi CBiIFGTE w►r BE �!®OR NAY PBirAR T1aU N811nANUE AIWORDED BYIHEPOUM VSKMEDNEDErrla=sjWrTOILLLTIETHiB,EXCURNOMNOCOMMONS OFSUCH POLICM LYBSIMNwYMMERMNOMUCEDaY PAD Ia AaLS TYPE OF aaiWN7CE GENERAL L IABIUTY o CMIA ma& GENERAL LIABILITY CLAMS MADE M OCCUR GENL AGGREGATE LIMIT APPLIES PER: POLICY [:] PROJECT M LCC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULE AUTOS HIRED AUTOS NON -OWNED AUTOS L AABRELLA LAB OCCUR EXCESS LIAB CLANAS-AAADE POLJ<FEFFDATE PMWEllPDATE POLICY MAIBER I (NNIODIYTm (f amyYm LIEU, IOCCLJRRENCE 0.GETO RENTED AISES {Ea ocamerre) EXP (Any are P—) K)NAL & ADV PUURY ERAL AGGREGATE DUM - COW/OP AGG LINED SINGLE INJURY OCCURRENCE RETENTION $ A WORKER'S COMPENSATION AND WC STAMORY EMPLOYERS LIABILITY YIN LIB-2E0003M-14 01272014 01272015 % LIYITS MIYPROPEWONPAWNERIEXECUTIVE WA E L EAC14 ACCOEM OFPAMPAA 31M DICLUDED? © E.L DISEASE - EA 8WLOYEE 3 700.000 plmdatmy a M0 r yea, dm mfm under E.L. DISEASE - POLICY LFAT $ 500,000 DESCRIPTIOII OF OPERATIONS hear DESCRIPTION OF OPERA? OfMOCAIU)NSIVEMCLESIRESTFWMONSISPECIAL ITEMS TIES 3tEnACESANYPRIORCEWnFtCA7EiSS WTOTHECIERWICATEHOLDBRAFFBCIINGWARSCOMPCOVHRAGE TOWN OF BARNSTABLE 367 MAIN ST NYANNLS, MA 02601 WM 25 (2DtUM The ACORD name and Iwo are SHOULD ANY OF TIE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE IHEREOF, WME WILL BE DELIVERED N ACCORDANCE WM THE POLICY PROVISIONS. Town of Yarmouth Conservation Commission Building Permit Sign -off Application TO BE FILLED OUT BY APPLICANT: Building Site Location: 2� �5�17i; N 5� Q5� IV, &tC- t��kri Map # 2_6 Lot(s) # b Property Owner: �/�V,t/ �r� V211-2✓Tf Applicant: If Applicant Address: Telephone: 3G'i — 3— ePl? Date Filed l t �1t Proposed Project Description: Plans: TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the Proposed Project Require a Permit? \__I) C) Comments from Conservati mmii Approved Conditionally Approved Rejected —All work related debris shall be taken offsite or disposed in a legal upland location I At the end of each day, the area shall be clean and no debris shall be in the Resource Area Refer to: SE83- or DOA permit Conservation Commission Sign -off Signature: Date: 11 _ J�+ t