HomeMy WebLinkAboutBLD-19-492 ,
. . _ of•YgR BUILDING PERMIT APPLICATION
• . =e S APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE,OCCUPAFJCy OF,':"
C O E J
it; + C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY WELLING _
y a 9 $, Town of \ trmouth Building Department i
..Z.fl
%-:44.,..„,Y0 1 146 Route `28 • Yarmouth, MA 02664-1492 AUG 0 7 2018
Tel: 508-398-2231 ext 1261 Fax 508-39&0836- )
Office Use Only Planning Planning Board Information Assessors Department Information: I "—..L_ _---__,„_----- ____ ,
Per �0bDligare Ran Type ,gQ��n/4 ,^,
Map � /�,fSSI'1�
Permit Fee Endorsement Date 97/ C4/
Recording Date , New
Deposit Rec'd. $_290 Date_ pian No. 1.4 Property Dimensions:
Net Due $ 4,\< Other Lot Area(sf) Frontage(ft) Lot Coverage
This Section for Office Use Only .
Building Permit Number. Date Issued: •
Certificate of Occupancy
Signature: • •..,--2:-.---/-,e r7—dc—I8'
Building Official Data is Is not required
Section 1 - Site Information
1.1 Property Address: �/ 1.2 Zoning Information:
9
Cb4 otjA CA-Call4 r
ffik Yavi..4444 M1 0 6y Zoning District Proposed Use
1.3 Building Setbacks(ft) '
Front Yard • Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.4 Water Supply(MALL c.40.S 54) 1.5 Flood Zone Infarmafiocc Comment •
Public Private Zone: BFE •
Section 2- Property Ownership/Authorized Agent
2 Owner f Record:
otvlrt�loGect�<tsitf go, Coi(ejtif Ati15540441 077
N ^^�� MailingAddress:y3S37-a13� w5,6--37-0v3/
-c
/
gnature Telephone
Telephone Email Address:
2.2 Authorized Agent ;—r------_______
— r
•
Name(print) /O/� • !!!!
I JULL 2 4 2018 1ail'mg Address•
I •
Signature Telephone '�-�JNuL�f•i,krmi.NrFax Email Address: I
Section 3-Construction Services
3.1 Lie sedonsts Supervisor:ti n SrviApplicable D]
6&441
Vt n Not:it1G90e22
1
3% Not:, Od. i'Tf'w,Vrl(e AA' G(Q
` license Number
Add,'r//esss #..-177„tr, /�� �a/a�/�a-4//_ (#3r2�33TC 1td-'i"M4nnQad-0 Q6 .pr' Expiration Date
Signature Telephone Email Address:
,/
3.2 Registered Home Improvement Contractor.
Company N ms' LLp Not'ppl�q _.a +'
Ii:Lt�L i:1ia.: • 'l ti Ceti s c•, cu a. 2( r .
Adtlrer/.^�20 •U qVCP 'e-C ' r ( Q55110107 Registratf n Number
_ , Expiion Date
Sig tore Telephone
Section 4-Workers'Compensation Insurance Affidavit(M.G.L c. 152 S 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- Professional Design and Construction Services-for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect
Not Applicable ❑
Name(Registrant): Registration Number
Address
Expiration Date
Signature Telephone
Section 5.2 Registered Professional Engineer(s)
Area of Responsibility
i
Nam*
AddressRegistration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Hama Area alResponsibility
AddressRegistration Number ,
Signature Telephone Expiration Date
Area of Responsibility
Hams
Address Registration Number
Signature Telephone Expiration Dale
Section 5.3 General Contractor
, Not Applicable l]
Company Hams
. \.
Person Responsible for Construction
Address
Signature Telephone
!-,
`* - , Section 6- Description of Proposed Work(check an applicable)
' New Construction ❑ (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms
' - • Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
•
Brief Description of Proposed
Work:
Ce AS 1.(v4- ou 2 x /awry
1 Q
o4t, o _
l�, a( plbe: ( cmc
✓
•
Section 7- Use Group and Construction Type
Building Use Group(Check as appricapabie) Construction Type
• A ASSEMBLY ❑ ,A-1 O A-2 ❑ A-3 ❑ 1.4
_ Al ❑ A-5 ❑ 18 la
B BUSINESS ❑ 2A ID
E EDUCATIONAL 0 28 ❑
F FACTORY ❑ F-1 O . F-2 ❑ 2c
H HIGH HAZARD ❑ 3A
I INSTmJTIONAL ❑ I-1 ❑ I-2 O I.3 9 38 ❑
M MERCHANTILE O 4 13
R RESIDENTIAL ❑ R-1 0 R-2 ❑ R-3 ❑ SA i]
S STORAGE ❑ S-1 0 S-2 O 58
U UTILITY C)
SPECIFY
M MIXED USE ❑
SPECIFY:
S SPECIAL USE ❑ SPECIFY:
Complete this section if existing building undergoing renovations,additions and/or change Iri use.
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height 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 110 11)
Independent Structural Engineering Structural Peer Review Required Yes.. No
SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. Darrevl t tcv-fAs , as Owner of the subject property,
hereby authorize 1qa 1 e404 (b Jdts aotilvekoil to act on
my beha f, in all matters relative to work authorized by this building permit application.
_ 4 1n--';
Sign re o •caner Date
1 ,.r a ,..,e..
•
SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION r !
Avven LWo(st(il
I, , as Owner/Authorized Agent
hereby declare that the statements andinformation on the forgoing application are true and acurate, to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
l avvt2 t?cvi1Sl •
Print h
V#1./1 712Y—‘,1)
Signa re of •wrier/Agent Date
Section 11 -ESTIMATED CONSTRUCTION COSTS
Item • Estimated Cost(Dollars)to be
completed by permit applicant
I.Building
<400. o0
z Electrical
3.Plumbing/Gas
4.Mechanical(HVAC)
S.Fire Protection
• 6.Total-(1.2+3+4+5)
' 7.Total Square Ft.tine mans I thThel /s0
Check Below
❑ Conservation-Commission Filing
(it applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
•
The Commonwealth of Massachusetts
`. „_——__� Department of industrial Accidents
_'ig'�:t Office of Investigations
•
=1a—
=� = • .600 Washington Street .
` Boston,MA 02111
•www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): )'1Vc S'v/
Address: 101 Cell,— gk1JA� 1 Sicrik iJic�ct M 0/0�7
City/State/Zip: Phone#: W7 -78 - ! 7f 7
Areyou an employer?Check the appropriate box:
I. intI am a employer with a(( 4. ❑ I am a general contractor and I Type of project(required):
have hired the sub-contractors . 6. ❑New construction
employees(fall and/or part-time).
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance? 9. 0 Building addition
required:] 5. 0 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.
❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0Roof re
insurance required.]t c. 152, §1(4),and we have no ars
P
—
3a.❑ I am a homeowner acting as a employees.[No workers' 13.0 Other
general contractor(refer to#4) comp.insurance reqs.].
'Any applicant that checks bra#1 must also fill am the section below showing their workers'compcnsatio4olicy information.
•
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new afdavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contactors 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 emplojer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information �(�
Insurance Company Name: �1TtkreCOMP
Policy#or Self-ins.Lic.#: 4iC— 11 — TO30 Y( . Expiration Date: .ONONOCT
Job Site Address: I 0-' vd%a outs/./i Ave, S ti--nM ply City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby c der the paths penalties of perjury that the information provided aboveis true and correct
•
Signattnz: �S Date: -7-? -/ �4
t/
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: . Permit/License#
Issuing Authority(circle one): •
1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
}pg'Y ' y TOWN OF YARMOUTH
0
BUILDING DEPARTMENT
• o - 'r"'"�y. 1146 Route 28,South Yarmouth MA 02664
• 508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at ( Cwl`v"ota '4! ► //VC
Work Address
Is to be disposed of at the following location: 440 C St'v Ccx
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
�ii2YAIA1
ignature of Appl cation Date
Permit No.
ovic.4 TOWN OF YARMOUTH
• e:"`�O
!� C HEALTH DEPARTMENT
hi
by$ PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 9 COIA'1 witigk H-C1
/ ,qvt
Proposed Improvement: t11tJA? &ACM61011
Applicant: qv, J fkr ert(4visene-M'F)Ovl 1 T$I C. Tel. No.: 1-43-5374/3/ t )
Address: 71 07 Cotkj.t Cfi LkJ) ,Spc4gU r/Ct A440/b-]7 Date Filed: 7-67V-13
•'Ifyou would like e-mail notification of sign off,please provide e-mail address:
Owner Name: 801 CQlkj`P mikky (�L� r � 7 /,3
Owner Address: 'O7 tile3� 14iA447/SnickwQ[1(,&4Q °�o7UwnerTel.No.: -71pg
97/7
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: P&A./.1 DATE: 7/�
PLEASE NOTE
COMMENTS/CONDITIONS:
- MGL AND FIRE
•
•
qtrtip,avTOWN OF YARMOUTH
REVIEWED FOR CODE COMPLIANCE.
ERRORS OR OMMISSIONS DO NOT RELIEVE
THE APPLICANT FROM THE RESPONSIBILITY
• 01)
OF"AS BIBLE'gOMJANCE.
DATE: .5 - 4S- / 0
44)
NSPECTOR
YARMOUTH FIRE PREVENTION
Commercial Construction Building Transmittal
Project Name: Five Star Transportation Address: 9 commonwealth Ave.
Contact Name: Darren Lecrenski Phone: 413-537-2131
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 I;22.3
*Service Stations 527 CMR I ;16.2.3,16.2.3.1,30.3.2
X *Hazardous Materials Storage 527 CMR 1;60.1
*Kitchen Exhaust Systems* 780 CMR,527 I;50.1
X Extinguishers 527 CMR I; 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 I;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 *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.
*Per 527 CMR 1 13.1.8, a permit is required from the Fire Department to shut down any
fire protection system.
Description of planned project/other requirements:
The YFD supports the applications, subject to applicable submissions,permits and
inspections.
Plan Reviewed By: Captain/Inspector Nevin Nadi Date: 7-25-2018
Copy for Applicant c1 Copy to Building Department II Copy to Fire Prevention
Entered in Firehouse I—I Final Inspection
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RUSSELL MA 01071 G'.`itt,`. iso ~``,,- .,i
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Co�istruction Supervisor
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NICHOLAS HAFTMANN ; z` �" i :. :' ; rt , : '',,
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..41`d/e0' CERTIFICATE OF LIABILITY INSURANCE DATE(27/2018'
06/27/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the polley(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
Eastern States Insurance
IE
Agency,Inc. PNOEse:7B1 642 9000 rill No):781 647.9670
50 Prospect Street L.
Waltham,MA 02453 PRODUCE:
PRODUCER
CUSTOMER ID i:FIVES-1
INSURERS)AFFORDING COVERAGE NAIC 1
INSURED Five Star Transportation,Inc. INSURER A:American Alternative insurance
809 College Highway LLC INSURER S:School Transportation Assoc
809 College Highway
INSURER C:Hanover Insurance Co. 22292
Southwick,MA 01077
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR°�R TYPE OF INSURANCE WSW
now POLICY EFF POLICY EXP
Ne WVD POLICY NUMBER (MMIDDIWYY) (MMIDDIYYYY) MARS
GENERAL LABIU Y EACH OCCURRENCE $ 1,000,000
A X COMMERCIAL GENERALIJABILITY X GPPAPF6056697 10/01/2017 10/01/2018 PREMsE5(EeoccurrFence) $ 100,000
I CLMMSMADE El OCCUR MED EXP(Any one person) 1 5,000
PERSONAL LADY INJURY $ 1,000,000
GENERAL AGGREGATE $ 3,000,000
GENL AGGREGATE UMR APPLIES PER: PRODUCTS.COMP/OP AGG S 3,000,000
—1 POUCY El JFRR n LOC $
AUTOMOBILE LLABLJTY CO• MBNED SINGLE LIMIT
A X ANY AUTO GPPAAU 405006440 10/01/2017 10/01/2018 (Es occident)
$ 1'000'000
ALL OWNED AUTOS BODILY INJURY(Per person) 1
BODILY INJURY(Per accident) $
SCHEDULED AUTOS
—
HIRED AUTOS PROPERTY DAMAGE $
(PER ACCIDENT)
NON-OWNED Comp/Coll _ s ACV
Deductible $ 1,000
UMBRELLA LAB X OCCUR EACH OCCURRENCE 1 9,000,000
X EXCESS LAB CLAIMS-MADE AGGREGATE $ 9,000,000
A GPPAPF 6056697 10/01/2017 10/01/2018
— DEDUCTIBLE $
RETENTION $ $
WORMERS COMPENSATION WC STATU• 0TH-
AltEMPLOYERS'LIABILITY TORY LIMITS ER
B M1YPRCPRIETORRARTNR CUTIVE YIN WC17-1503041 01/012018 01/012019 El. EACHACCIDEMT S 1,000,000
OFFICERMEMBER EXCLUDED? NM
(Mandatory In NH) E L.DISEASE•EA EMPLOYEE 5 1,000,000
Ryes desonide under
DE SC`RIPTIONOFOPRATIONSSlow EL DISEASE-POLICYLIMR s 1,000,000
C Equipment Floater RHND10308300 10/01/2017 10/01/2018 Dad 1,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEMCLES (Attach ACORD 101,Addltlnnel Remarks Schedule,N mere apace la requirieg
?r05111e?runty pd �ali Is listedgar .ommonw IImd.,Sh res t vena I
unty c n regar ommonwea Ave., o. arm act to mA. O day
canoe tion clause appt es
CERTIFICATE HOLDER CANCELLATION
WESTFVA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Westfield Bank I$AOA/ATIMA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH 1HE POLICY PROVISIONS.
do MOA Hazard Tracking,Inc.
C/o Lee&Mason Financial Sery AURFERRED REPRESENTATIVE
P.O.Box 8277
Reston,VA 20195 5A–•--
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01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
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