Loading...
HomeMy WebLinkAboutBLD-19-001046 r Ir . i` . of•YgR BUILDING PERMIT APPLICATION • . 44- -v.,., APPLICATION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE,OCCUPANCY OF, to_ C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELUNG. tt Sy Town ofYamouth Building Department `. ",ce 1146 Route 28 • Yarmouth, MA 02664-1492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836YP 1 .^—ppa 1 — S. i ct 11 j Offiice/Use /Onl y�/ / Planning Board Information Assessors Department Inlormatiol{: Pefmit.A./.0-19-�!/�Qdt@ C/ Plan Type ' —__ �_ __f1. 0 V Map Lot I! 20 ZULU Permit Fee $lL� Endorsement Date moo/ I ��/ tl� Recording Date Nei, i°ilii A(:ir. ; ii I Deposit Recd. $,0 Date Plan No. 1.4 Property Dimensions: I " TT-- _ Net Due _ $ 0 / Other i Lot Area(at) Frontage(It) Lot Coverage This Section for Office Use Only . Building Permit Number. / Date Issued: Signature: -�✓G 2— 6'1 ,---/.4e Certificate of Occupancy Building Official Date is is not required Section 1 -Site Information 1.1 Property Address: 1.2 Zoning Information: 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.o.40.S 54) 1.5 Flood Zone Information: Comments Public Private Zone: BFE • Section 2- Properly Ownership/Authorized Agent 2.1 Owner of Record: Prirea&IS X ?eV v70/? no.30. aG1r ifinvAlis Name(print) Mailing Address: 0 Signature Telephone Telephone Email Address: 2.2 A/uthorized Agent 2 Clic - . /4D5�(� 304( In /5ti 1/( C7r(n.,!A Si Cli (��j`ii07 flame(pr • I / Mailing Address: ign:ture Cr /--Telephone Fax Email Address: j Section s-Construction Services 3.1 Licensed Construction Supervisor Not Applicable I] License Number Address • Expiration Date Signature Telephone Email Address: . 3.2 Registered Home Improvement Contractor.( r Company Name Not Applicable ❑ . Registration Number Address Expiration Data Signature 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) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of ResponsiResponsibility. Address Registration Number Signature Telephone Expiration Date Hams • Area of Responsibility , - Address Registration Number • Signature Telephone Expiration Date Hams Address Area of Responsibility Registration Number Signature Telephone Expiration Date - Section 5.3 General Contractor Not Applicable CiCompany Hams Person Responsible for Construction Address Signature Telephone • Ir ' • , Section 6 - Description of Proposed Work(check all applicable) '" ' .,_New Construction ID (tor 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: A4*Je - Par- i- Cann';Ak- oma/ i<'Tcttpj .Y`347N 7/1r S,5 vit.,/ Section 7- Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type • A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ to ❑ A-4 ❑ A-S ❑ 1B ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL ❑ 2B ❑ F FACTORY ❑ F-1 ❑ . F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I.1 ❑ 1-2 ❑ 1.3 ❑ 3B ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL 0 R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S STORAGE ❑ S-1 ❑ 5-2 ❑ 58 ❑ U UTILITY ❑ • SPECIFY: M MIXED USE O SPECIFY: • S SPECIAL USE Cl SPECIFY: Complete this section if existing building undergoing renovations;additions and/or change In 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 pi 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 OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT a- -SIS A , as Owner of the subject property, hereby aut 'ze 1.11 Q /?P,4r^Y f' to act on vmyy be 4011 p ers 've w Al Ithorized by this building permit application. 49- E tt01, /Oda S gnature • Owner Date I nl 4 liven • 1 s SECTION 1ObOWNER/AUTHORIZED /AGENT DECLARATION ' I, _A_ lb, a • tweak ast orized Agent J hereby declare that the statements and informatio on he forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. P iN P5®rL (oe�,9 ": ,� • :, . + ,' -.l . _ , ' L/ ..• g —/0rtoD0() . Signatu - _ = • r;Agent Date • Section 11 - ESTIMATED CONSTRUCTION COSTS Item • Estimated Cost(Dollars)to be completed by permit applicant 1.Building a Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection 6.Total-(1♦2.3.4.5) ' 7.Total Square Ft(krr.w mourn a as6bel 0 Check Below ❑ Conservation-Commission Filing (if applicable) 0 Old Kings Highway&Historical Commission approval (if applicable) • ., .• ,t • The Commonwealth of Massachusetts Department of Industrial Accidents =Iii'• -4 fOffice of Investigations -_1Q— 600 Washington Street • � = .,..• el Boston,MA 02111 -www.massegov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers A Brant Information Please Print Le k t/ Name (Business/Organization/Individual): CUR b ej/1-19(}' - Address:9 vim?Iti 1A S1 (,)ct yegliti()aft City/State/Zi.: Phone#: _0 Are you an employer?Check theappropriate box: 3 Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ,employees(fall and/or part-time).* have hired the sub-contractors . 6. ❑New construction 2.01 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub contractors have g. 0 Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance Comp.inc ante t 9. 0 Building addition required:] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.El 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 ❑Roof Spain insurance required.]t c. 152, §1(4),and we have no 3a.❑ I am a homeowner acting as a employees.[No workers' 13.❑Other - general contractor(refer to#4) comp.insurance required.). 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensatioOolicy infotma5on- ners this IHomeow thathooeck thisbox must submitaffidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indieating such. attached an additional sheet showing the name of the sub contractors and state whether or not those entities have employees if the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lic.#: . Expiration Date: Job Site Address: City/State/Zip:, Attach a copy of the worker'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. I do hereby certify under the pains andytnalties of perjury that the utfor:ration provided above is true and correct �S Date: ^ 01O — © 9 • 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#: Information and Instructions ` Massachusetts General Laws chapter 152 regtums.all employ&z to provide workers'compensation forof oy , Pursuant to this statute,an capbya is defined as"_.every person is the service oany contract lire, another under express or implied,oral or written." An employer is defined zeta individual,partnership,association,corporation or other legal entity,or any two or mom of the foregoing engaged in a joint enterprise,and inching the legal representatives of a deceased employer,or aloe receiver or trustee of an iadivickal,partnership,association or other legal entity,employing eroployeen However the owner of a dwelling hoes having not more than three apartments and who reside therein,or the occupant of the dwelling hoose of another who employs persons to do nwhItPesnes,construction or repair work on such dwelling house or on the grotmda or building appy thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing zgeacy shall withhold the Inmate or renewal of a license or permit to operate a business or to construct ballasts la the commonwealth for any appdcast whit has not produced acceptable evidence of comp/Canes with the lasrssee txverate required. • ArtriiSonttly,MCL chapter 152,125C(7)states"Neither the commonwealth nae any of its political subdivisions shall • public owork tmuntilacceptable evidence of compliance with the mucic eater into any contract foe,the perforate=perforate= requirement'of this chapter have been presented to the contacting authority." • Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation sad,if necessary,supply sub-contractors)name(s),addresa(es)and phone=hers)along with their certificate®of innaaace. Limited Debility Companies(LLC)or Luted Liability Pumaships(LLP)with no envbyea other than the i=Kmben or partners,are not required tom workers'=pentad=insurance. If an LLC or LLP does have .employees,a policy is teed. Be advised that this affidavit may be submitted to the Department of Industrial • Accidents for confi e:nioa of inttnxs coverage. Ala be run to riga and date the affidavit. The affidavit should be rewired to the city or town that the application for the permit or license is being requested,not the Departing of Industrial Ate. Should you have any questiooa regarding the law or if you am required to obtain a workers' compensation policy,please cell the Department at the a®ba listed below. Self-insured compenies should enter their self-ir alicense surbe on the appropriate litti • City or Town Whisk Please be sure that the affidavit is complete and printed legibly. The Department has provided i space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to coated you regarding the applicant. Please be sure to fill in the pant/license r uith r which will be used as a reference mother. In addition,an appliaat that rant submit multiple pamitl[ieass appliatioas in any given year,need only submit one affidavit indicating current policy inhume(if necessary)and under"lob Sits Address"the applicant should write"all banner in (city or town)."A copy of the affidavit dist has been officially stamped or narked by the city or town may be provided to the applicant u proof that a valid affidavit ha on file for future permits or licenses. A new affidavit and be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or contercial ventre (Le.a dog license or permit to burn leaves etc.)said person is NOT required to convicts this affidavit The Office of Investigations would line to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give m a alL the Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Dales of Invetiptions • 600 Washington Street Boston,MA 02111 Tel. it 617-7274900 ext 406 or 1-877-MASSAFE. Fax,k 617-727-7749 • • Revised 11-22-06 • www.massgov/dib :at nti. y TOWN OF YARMOUTH ! O BUILDING DEPARTMENT • o "€ y 1146 Route 28,South Yarmouth,MA 02664 • cm/C-1.:' j. 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMO ► ITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 1,Section 54 and 780 CMR, Chapter I, Section 111.5, I hereby certify that the debris res' ting from the proposed work/demolition to be conducted at Work Address Is to be disposed of at the following locatio•: Said disposal site shall be a licensed solid waste . ility as defined by M.G.L. Chapter 111, Section 150A. Signature of Application Date Permit No. *oo r plan COMMERCIAL ONLY-BUILDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: Scope of Proposed Work: Date: Based on the scope of work described above,the applicant is required to obtain approval sign-offs from the following departments as checked-off below: INITIALS Health Dept.—508-398-2231 ext. 1241 Conservation Comm.— 508-398-2231 ext 1288 Water Dept.— 99 Buck Island Rd. phone no.508-771-7921 Old Sings Hwy.Hist. Comm.—508-398-2231 ext. 1292 Engineering Dept.— 508-398-2231 ext. 1250 V Fire Dept.— evin HuclQames Armstrong,96 Old Main St. SY -'ZO -j% Note: Please call Fire Department for an appointment. 508-398-2212 / pS Other Appropriate plans and/or application shall be provided to each of the departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for cooperation. Receipt Acknowledgement: Applicant's Signature Date Rev. Dec. 2015 • MGL AND FIRE 111 .� MCP TOWN OF YARMOUTH REVIEWED FOR CODE COMPLIANCE. ,i ERRORS OR OMMISSIONS DO NOT RELIEVE �j THE APPLICANT FROM THE RESPONSIBILITY otn. / OF AS BUILT"COMPLIANCE. DATE: 3"Zo-/ C.A77. IN INSPECTOR YARMOUTH FIRE PREVENTION New Business Transmittal Project Name: Cape Kitchens and Bath Address: 26 Route 28 Contact Name: Wadson Braga Phone: 508-776-7831 Y N NA Subject Regulation ES 0 11 X Building Numbers MGL Chapter 148;sec 59 X Fire Lanes 527 CMR 1;22.3 X _ Extinguishers 527 CMR 1; 13.6,Chapter 148;sec 28 X Maintence of any equipment,system relating to 527CMR1 1.1.4 Fire Protection. X *Hazardous Materials Storage 527 CMR 1;60.1 X Emergency Plan Required 527CMR1 10.9.1 X Commercial cooking,Hood systems 527CMR1 50.2.1.1 X Commercial Cooking Hood Systems Cleaning 527CMR1 50.5.4 X *Commercial Cooking Extinguishment System 527CMR1 50.4.3 X *Candles,open flames,and portable cooking 527CMR1 17.3.2,20.1.1.1 X Blocking electrical panel 527CMR1 10.19.5.1 X Blocking exits 527CMR1 14.4.1 Extension cords shall not be used as a 527CMR1 11.1.7.6, 11.1.7.1 X substitute to permanent wiring X Limit storage heights to 24 inches below 527CMR1 ceiling without sprinklers 18 inches with X Maintain Aisle width of 36 Inch's(3 Feet) 780CMR 1101.1 Xt Storage inside/outside Buildings 527 CMR 1; 10.19.4,4.4.3.1.1,19.1.2,34.1.1 X The right to inspect MGL Chapter 148 Sec.4 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 Description of planned project/other requirements: The YFD support the application, subject to applicable submissions, permits and inspections. * YFD permit required-depending on occupancy and submittal Plan Reviewed By: Captain Kevin Huck Date: 08-20-2018 Copy for Applicant 7J Copy to Building Department II Copy to Fire Prevention Entered in Firehouse n Final Inspection s st TOWN OF YARMOUTH '.".to HEALTH DEPARTMENT r\ eVt PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: C ,, / Building Site Location: X 06 G.,5r /nrq,',, 51 RA- 5-r yeemnitro 71f Proposed Improvement: U 56 4- (DCCO PA /JCCL( — S t4-0t.J200M 04-04 S trap eoVel-seta-T) Applicant: LUAJD6On/ 30,4 (-74 Tel.No.: c00 -776 - f3/ Address: a6 (14$t MAlt' 57- ()A'.67" �f40tt19v1�H Date Filed: [� -1G ( �j **Ifyou would like e-mail notificationofsign off please provide e-mail/ address: Owner Name: FT/ ia-tut. r 5 It Owner Address: 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: ( t DATE: G ^ l 6 -18 PLEASE NOTE COMMENTS/CONDITIONS: o J go C/A .e. 0/L fS'r.'f c wtc,1 — No C_4etnt calf tEl f . I 13Ac K Dmdn ll JM ` oftpG16 J YARMOUTH\_______________-- .._r_—' . TOWN! OF REVIEWED FOR BUILDING AND ZONING CODE COMP!). SANCE. ERRORS OR OMM!SS!ONS DO NOT RELIEVE THE'0 fir` APPLICANT FROM THE RESPONSIBILITY OF 'AS BUILT' CJ 3��K DA7C•LIANC�_ / +//f i J n JM1 ?l• C r • ILDINGOFFICIAL % I 01.4' FILE COPY; c>414- 38 S� �pUll� © � ~ AUG 16 2018 HEALTH DEPT. ate ...±. \ EAST MA OW?F(lpn1T OW?6 is , 16 -1/