HomeMy WebLinkAboutBLD-19-001047 . • , 01..YgR BUILDING PERMIT APPLICATION &F
. Z'F 4 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF,
c OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
•'• '• 0 X11 _ S Town of Yarmouth Building Department
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3.2 Registered Home Improvement Contractor. -
Company Name Not Applicable ❑ . , ,
•
M ,
Registration Number •
Address
Expiration Date
,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
Area of Responsibility
Name
Address Registration Number
Signature Telephone • Expiration Date
.. ,
NameArea of Responsibility
Address
• • • : Registration•Number" - \
'
Signature Telephone Expiration Date
Area of Responsibility
Name
Address Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor
Not Applicable ❑
Company Name
Person Responsible for Construction ° I" ' ,_ii.;
Address
Signature Telephone
2of4
Section 6- Description of Proposed Work(check all applicable)
' New Construction ❑ (lor multiple family only) No.of Bedrooms (for multiple family only) No.01 Bathrooms
Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑ •
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
DA
kankli%) A —a\ S zAilk�a‘,1\s 62 22.,a64/
f aRPca 6s 0147
Section 7- Use Group and Construction Type
Building Use Group(Check as apprcapable) Construction Type
• A ASSEMBLY ❑ A.1 ❑ A-2 ❑ A-3 ❑ IA CI
Ad ❑ A-S ❑ is ❑
B BUSINESS ❑ 2A ❑
E EDUCATIONAL I❑ 28 ❑
F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL ❑ I.1 ❑ 1-2 ❑ I.3 ❑ 3B ❑
M MERCHANTILE ❑ . 4 ❑
R RESIDENTIAL ❑ R-I ❑ R-2 ❑ R-3 ❑ SA ❑
S STORAGE ❑ S-1 ❑ 5-2 ❑ s8 ❑
•
U UTILITY • ❑
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(sl)
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 1 Oa OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRAC R APPLIES FOR BUILDING PERMIT
PR'4 u C/ X �� Q , as Owner of the subject property,
hereby authorize-fraer4 A NF Acquie to act on
my behal all matters rela ' ate-work authorized by this building permit application.
81
/ Signatu o(Owne / Date
I
3 of 4 OVER
SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION
I. hR w S?Wr ` , b+ " Vig , as Owner/Authorized Agent
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hereby declare that the statements and information1n the forgoing application are true and acurate, to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury. •
•
Print N. •e
Signature of Owner rent Date, •
Section 11 -ESTIMATED CONSTRUCTION COSTS
Hem Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
2.Electrical
3.Plumbing/Gas
4.Mechanical(HVAC)
5.Fire Protection
•
e.Total-(1.2+3.4.5)
7.Total Square FL Ib new ennuis a aeditoml
Check Below
❑ Conservation-Commission Filing
(if applicable)
U Old Kings Highway&Historical
Commission approval
(if applicable)
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40( 4
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,,% • The Commonwealth of Massachusetts
Department of Industrial Accidents
t.--.=fl
. •' , '.—; Ofjiceoflnvestigations
=lj ems= •
600 Washington Street
U' `` Boston,MA 02111
-www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
•
• Name (Business/Organhationandivvidual):M 1S ASA ilI'Y A cleoa'-rq 4V-TS (S CI9&
/Address: t) a 1:-,,� AAM ill 3 19
I . eC� 40116'd-1in
1
City/State/Zip: Q�( 9_3 Phone#: &&5t- (11)- 9*( 9.-
Are you an employer?Check the appropriate box:
I am a generalType of project(required):
4.
1.❑ I am a employer with 0 contractor and I
have hired the sub contractors . 6. El construction
employees(full and/or parttime).*•
2,Q] I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
�\ ship and have no employees These sub-contractors have g, 0 Demolition
working for me in any capacity. employees and have workers'
9. 0 Building addition
[No workers'comp. insurance comp•insurance.
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 . 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no —
3a.❑ I am a homeowner acting as a employees.[No workers' 13.0 Other
general contractor(refer to#4) comp.insurance required.].
'Any applicant that checks box#1 must also fill out the section below showing thea workers'compensatiodpolicy mfonnaiion.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside conuactots 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 nut
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 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.
I do hereby certi u•do the pal nd penalties of perjury that the information provided bore is true and correct
t •
i
7ST
�Senature: 1„ 11 Date: �r/) •
vil I
Phone#: i
•
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 requ¢es.all employers to provide workers'compensation for their errploya'n.' •
Pursuant to this statute,an employee
is defined as"_.every person in the service of another under any contract of the,
express or implied,oral or written."
corporation or other legal entity,or any two or more
An rsrplt�is defined as as individual,partnership,association, �t of a deceased employer,or the
of the foregoing engaged in a joint enterprise,and including the legal representatives
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner 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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an=playa."
MGL chapter 152, ¢25C(6)also states that"every state or local licensing spumy shall withhold the issuance or
renewal of a license or permit to operate a business or to construct bdldhp la the commoatwaltk for say
applicant who has not produced acceptable evidence of compliance with the Ins rsaee average required."
Additionally,MGL chapter 152,¢25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contact tot the paformame of public work until acceptable evidence of compliance with the insurers
requirements 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 and,if
necessary,supply sub-contractors)name(+),address(a)and phone nuumbes(s)along with thea cati&ate(s)of
insurance. Linsited liability Comps(LLC)or Limited liability Partnerships(LLP)with no employees other than the
members or patinas,are not required to carry workers'compensation insurance. If an LLC or Lilt does have
Beadvised that this affidavit may be submitted to the Department of Industrial
employee;a policy is tknrequof Ahs be sure ts slap and date the affidavit. The affidavit should
Accidents tae S citytmtioo onttheinsurance coveragenot the Department of
be returned to the or town that the application for the permit or license is being requested.
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,plena call the Department at the number listed below. Self-insured companies should enter their
self-insurance license mmmba on the swopdsw line.
City or Taws Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided i span 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 nae to fill in the pertnitl icease number which will be used as a referenea number. In addition,an applicant
that must submit multiple pamvlicense applications in any given year,need only submit one affidavit indicating current
policyinfatuation(if necessary)and under"lob Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit St has been officially stamped or marked by the city or town may be provided to the
applicant is proof that a valid affidavit is on file fix future permits or licenses. A new affidavit mut to filled out each
year.Where a boos owner a citizen is obtaining a license a permit not related to any business or commercial ventre
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a cane
tete Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax 1!617-727-7749
Revised I1-22-+)6 www.rnass.govldla .
`o* Y'i _ TOWN OF YARMOUTH
to BUILDING DEPARTMENT
n' o y 1146 Route 28,South Yarmouth,MA 02664
• <, _„3 508-398-2231 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 S,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at
Work Address
Is to be disposed of at the following location:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Application Date
Permit No.
alai? /14-ni
COMMERCIAL ONLY-BUILDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: .$&\ 1\C\I\V1) �S \14:NC) , '.
I)
Scope of Proposed Work: SH-- 1 icic1C1 vm 'C" ScIaR A61-71:%1V
. cc \'`)
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
7 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 Kings Hwy. Hist. Comm.-- 508-398-2231 ext. 1292
Engineering Dept--508-398-2231 ext. 1250
Fire Dept—Kevin Huck/James Armstrong,96 Old Main St. SY .jin 9 /1-1-
Note:
1-1-Note: Please call Fire Department for an appointment. 508-398-2212 j'
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.
ReceippttjAcknnoowledgement:
AA
Applicant's Si nature N Date
Rev. Dec. 2015
MOL AND FIRE
TOWN OF YARMOUTH
J
'lips
E COMPLIANCE.OSIONS DO NOT RELIEVE
M THE RESPONSIBILITYPLIANCE.
INSPECTOR
YARMOUTH FIRE PREVENTION
New Business Transmittal
Project Name: Kitchens and Countertops Direct Address: 22 Route 28
Contact Name: Christopher Harvey Phone: 508-771-7864
Y N NA Subject Regulation
ES 0
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 527CMRl 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 527CMRl
ceiling without sprinklers 18 inches with
X Maintain Aisle width of 36 Inch's(3 Feet) 78OCMR 1101.1
X Storage inside/outside Buildings 527 CMR I; 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 I;20.6.2.5
X *Trash Containers 527 CMR l; 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: 08-14-2018
Copy for Applicant Copy to Building Department I I Copy to Fire Prevention
Entered in Firehouse Final Inspection
Quite TOWN OF YARMOUTH
oEcs ; '�,��� . HEALTH DEPARTMENT
'�•% PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: 1 Q�
Building Site Location: D..0. n{� V�'�1IU , \ kOva) ) \' \�SC_
Progosed Improvement: -11 i ' �_ 4 ►_ ; 4 Lb s1'
o MV\ Nt\ Cin ctt3 CIBC 1n) �
Applicant: C,tie J c () PI \-1 Five( Tel.No.:5O1-r11 C
Address: a c- )"I% f) �1� . $6410)\\\\ Date Filed: ••
""/fyou would like e-mail notification of sign off pleaseprovide e-mail address: \1\���\r,Qn4kR 5 I �'ikI1lerJ,kt
Owner Name: c R ROC'
OC �C�'1� 1�Q 1.\ \'p c�,
Owner Address: C \t(� U)"[l,test)9 �.1, �'1 k Owner Tel.No.: Scq e rScitia
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: LW if'e DATE: (9'741e
PLEASE NOTE
COMM>A.020OG iNDIN/i 9 ( Ja , 4I 0� DI— g 4
Cit%pL t4,9./A , ,ie O1-s• PHD !moi
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1"\ \VH - ( / / )
•
TOWN OF YARMOUTH
n REVIEWED FOR BUILDING AND ZONING CODE COMPLI-
\r‘0 „�� ANCE. ERRORS OR OMM!SSIONS DO NOT RELIEVE THE
. APPLICANT FROM THE RESPONSIBILITY OF AS BUILT"
• CO?IFLIANCE
DATE: —a lO/B.;Lm.:
BUILDING OFFI
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