HomeMy WebLinkAboutBLD-19-188 oy Y.R BUILDING PERMIT APPLICATION V M 122;11(
••- .=F 'r0 APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF,
• to C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
• F � Town of Yarmouth Building Department
`�, �=: :%^p' 1146 Route 28 • Yarmouth, MA 02664-1492
Tel: 508.398-2231 ext. 1261 Fax 508-398-0836 _
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OfficeUseOnly / Planning Board Information Assessors Department Information
Permi D J girl/r+Ql Plan Type Map L
Permit Fee $ /70 Endorsement Date y// /
Recording Date New
Deposit Recd. $,Date_ plan No. 1.4 Property Dimensions:
Net Due $ / 35-- ...- Other Lot Area(sf) Frontage(It) Lot Coverage
This Section for Office Use Only
Building Permit Number. Date Issued:
Signature: /�J,//4" 9 3 Certificate of Cccu5aRyE C E I V E__13
ice Official rfJJ Date is Is not required
Section 1 - Site Information AUG 24 2018
1.1 Property Address: 1.2 Zoning Information nd peur
•
; nAeha I Zoning District Proposed Use
1.3 Building Set eke(et)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.4 Water Supply(MILL.e.40.S 54) 1.5 Flood Zone Intormabon Comments
Public Private Zone: BEE:
Section 2- Property Ownership/Authorized Agent •
2.1 0 or of Record. /(/��,���,�,� / (y�. �,�(��, ( (�
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(y��j��r �r eta
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Mailing Address:
1 r * . ,6
el - t r. Telephone Telephone 7
Email Address:
2.2 Authorized Agent:
Ha int Mailing Address:
n1 c.ri �ii(a2.7lron6
Signature Telephone Fax Email Address:
Section 3-Construction Services
3.1 Licensed Construction Supervisor. Not Applicable i]
'alnil wont
S." 1•./r2-Thi qs I-nM__ •nW-Wra License Number
Address n �7fn
g7
. aa? {JN6 +y• LVED Expiration Date
Signature Telephone n, 41cres;:
wet-0
' BUILDING DEPARTMENT
ilscihrstexisseievecOVER
•
-
3.2 Registered Home Improvement Contractor. •c
Company Name Not Applicable ❑ • - -•
Registration Number
Address
Expiration Date
Signature Telephone
Section 4-Workers'Compensation Insurance Affidavit(M.G.t_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)i •
Name Area ol Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name • Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name • Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor
Not Applicable 0
Company Name
•
Person Responsible for Construction
Address - •
Signature Telephone
2 o1 4
Section 6 - Description of Proposed Work(check all applicable)
_;. New Constructio0 ❑ (tor multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms
Existing Bldg. ❑ Repair(s) 0 Alterations ❑ Addition ❑
Accessory Bldg. 0 Type Demolition Other Specify:
Brief De tion of Proposed Work:
14ss 6!Y 16 sic L 10 ` } , I7 hPe, lei
l'piA-c LtirP t i ,at,,ttr g
. Section 7- Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
• A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
_ A-4 0 A-5 ❑ 1B ❑
B BUSINESS ❑ 2A Q
E EDUCATIONAL 0 28 0
F FACTORY ❑ F-1 0 F-2 ❑ ' 2C 0
H HIGHHAZARD ❑ 3.4 ❑
I INSTITUTIONAL ❑ I.1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A 3
S STORAGE ❑ s-1 ❑ 5-2 ❑ 53 0 .
U UTILITY ❑
SPECIFY: •
M MIXED USE ❑
SPECIFY:
S SPECIAL USE ❑ 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(it applicable) . Proposed
Number of floors or stones - .
include basement levels '
Floor Area per Floor(sf)
Total Area All Floors(sf)
Total Height(It)
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' AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, '-f t+ ` •rI a I ' ,as Owner of the subject property,
hereby authorized 1 4 ' • 4 to act on
my b .,f, intip. relative to work authorized by this building permit application.
i
3 .z.(8'
• S•nature of Owner Date
3 of 4 OVER '
•
SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION ►, .
Y �•
I, , as Owner/Authorized Agent
hereby declare that the statements and information on the forgoing application are true and acurate,to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
•
Print Name
Signature of Owner/Agent• Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit apprrant
1.Building
a Electrical
3.Plumbing/Gas
4.Mechanical(HVAC)
5.Fire Protection
5.Total-(1+2.3+4+5)
' 7.Total Square Ft.Par new:Mann t'Wiwi)
Check Below
❑ Conservation-Commission Filing
(if applicable)
U Old Kings Highway&Historical
Commission approval
(if applicable) •
•
4 of
• ' The Commonwealth of Massachusetts
`' Department of Industrial Accidents
=—_
'` t Office of Investigations
`•
pa r .600 Washington Street
-- •
`�- ` Boston,MA 02111
"�`•' •www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� Please Print Legibly
Name (Business/Organizathdt • ),n cab t1 *3 I�)AO IS
Address: S1, t i l
City/State/Zip: �S� 14tw,Cli 1 Phone #: -ba3 1' 7 119c)--2S..---
Are you an employer? Check the appropriate box: ______r—
I.❑ I am a employer with 4. 0 I am a general contractor and I Type of project(required):
employees (full and/or part-time).* have hired the sub-contractors . 6 ❑New construction
2.1
\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. insurance.? 9. 0 Building addition
required:] 5. ❑ 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 12.0Roof 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 their workers'compeasationpolicy info on. .
Homeowner who submit this affidavit inriir2ting they are doing all work and then hire outside convectors must submit a new affidavit indicating such.
:Contractor that check this box must attached an arliiitinnal sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contactors have employees,they must provide their worker'comp.policy number-
./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 ce under the pains and penalties of perjury that the information provided above is true and correct
Simature: 1 . Date:
yt"
Phone#: 5 -S7 % •
Official use only. Do not write in this area, to be completed by city or town official
City or Town: . Pertnit/License#
Issuing Authority(circle one): •
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
_ 1"Y.q ato • TOWN OF YARMOUTH
: . � ' •
e BUILDING DEPARTMENT
4‘1. $ 1146 Route 28,South Yarmouth,MA 02664
cspz
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 1113,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at
ork 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.
•
•
J
YARMOUTH WATER DIVISION
99 BUCK ISLAND ROAD
WEST YARMOUTH, MA 02673
PH.: 508.771.7921
FAX: 508-771-7998
•
BUILDING PERMIT APPLICATION
DEPARTMENTAL SIGN OFF TRANSMITTAL SHEET
•
Bldg. Site Location £'( ) & tZT 26 ►wwOc
Y
Proposed Improvement: • b 17 Vie,,,, h�4 5
Applicant: ..ccfibledRS'('•p�
AddreesgCOY bf n\pd Q`frgel. #:((S >]�y'Ov Date Filed: .2_1 gre
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RESIDENTIAL AND / OR COMMERCIAL BUILDING
•
V.atc-.Dcpd-trr ' : DCterrn nes Coirip.iance of V•a:er Availability and or Ex sting Locatior
Engineering Department; Determines Compliance for Parking and Drainage
Conservation Commission: Determines Compliance to Wetlands Acts;i e. IF Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Ocean, Bogs, Bays, Marshland, Etc
Health Department Determines Compliance to State and Town Regulationss , i.e., Requirements
for Septage Disposal and other Publrc Health Activit e
R'e Depa to ent Determines Comphance
pace to State and Town Requirements for Persona',
S:
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PLEASE NOTE:
COMMENTS:
Reviewe by: Water Di ion G d I
Date
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rOfOce of Consumer Arians& lie sincss Regulation
..ic:..;',�,HOME IMPROVEMENT CONTRACTOR
cy Massachusetts Depaurnent of Public Safety ,1- Registration: 128460 Type'
Board of Building Regulations and Standards i '�`� „ > it Expiration: . 8!292018 Individual
License: CS-071544 •,. . -
Construction Supervisor -. ' + JOHN DAVIS
z . _:- t
JOHN M DAVIS .�iy,-::yg4; JOHN DAVIS
52 NORTH ROAD ,,..Q-:-.:k..,-a.,r` 52 NORTH RD. . • -. + -
WEST HARWICH MA 02671 �_. .-,;r.ir
WEST HARWICH,MA 02671 Undersecretary
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M 1 1i{,� Expiration:
• `Commissioner 05/0712020
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REVIEWED FOR BUILDING AND ONING CODE COMPLI. '
ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT"
COMPLIANCE. 1
APPLICANT'S COPY DATE: g---- 3-/E3 • .:'s::;•;• r=,::,t.
"BUILi
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REVIEWED FOR BUILDING AND ZONIINNGG C}DE•OMPLI-
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APPLICANT FROM THE RESPONSIBILITY OF "AS BUILT"
COMPLIANCE. _Er:tri
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W EXIST SCREENED PORCH
DP EXIST OPEN PORCH N/F BASS RIVER REALTY. LLC
t oast SHOWER
DOST moa LC. PLAN 29957A •
EXIST CATCH BASIN
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SEINE POND CONDOS 1 •
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TOTAL AREA=10. 7 ACRES± Pace •
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LOCUS IS A.M. 41, PARCEL 17 . -
STRUCTURES SHOWN ARE ALL IN ZONES X ON FIRM DATED JULY 16, 2014.
MOST STRUCTURES ARE IN THE 0.2% ANNUAL CHANCE OF FLOODING.
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• SITE PLAN
PORTION OF
• YARMOUTH COUNTRY CABINS
864 TO 878 RTE 28, SOUTH YARMOUTH, MA
. JUNE 1, 2006 SCALE: 111=40' ° o--0 .
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• RONALD J. CADILLAC, PLS, RS, P.C. /y
PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN
P.O. BOX 258
WEST YARMOUTH, MA 02673 •• /' P00
AREA
• (508) 775-9700 N/F C `\
CAPOBIANCO \
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I ROUTE (STATE NORWAY-4W WOE) 28 •
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WORK MUST % 4 RM TO ALL
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EGEIW[ D YARMOUT ATER DEPT DA
JUN 222018
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HEALTH DEPT.