HomeMy WebLinkAboutBLD-19-000478 l49141(el-lee r
d ONE & TWO FAMILY ONLY-BUILDING PERMIT 'r Ai, i
Town of Yarmouth Building Department
Is.., 1146 Route 28,South Yarmouth,MA 02664-4492 � .
508-398-2231 ext. 1261 Fax 508-398-0836 r
• Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Mo-Family Dwelling
Thi Section�For Official Use Only
Building Permit Number: 1370 -/frVW .Date Applied
Building Official(Print Name) • Signa re , Date
• • .SECTION 1:SITE INFORMATION • •
1.1 Property Address: 1.2 Assessors Ma &ParcelNumbers
2.8 Act-cone, i),j use')act & \- gas
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: •
Zoning District Proposed Use Lot Area(sq fr) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private / Zane: Outside Flood Zone?
—
cheek if � Municipal 0 On site disposal system ❑ •
• " . •SECTION2i PROPERTY OWNERSHIP' ..
2.1 Owner'of Record: +,�, f _ ��M////' • to?) Cy •QtSG .
ecose. . 4 v./ Get tiwift (nL i!. as, meal:.
JSP I � :
Name(Print) 4 esi 1 ZIP
-tate,
iy3 CasTSt-
ff i firs" rq' t ":":> ktitticewoI teVa At -._#a Al.- a • I.._. 6 ..1 Il, 63d1
No.and Street Telephone A. iT�� Email Address
. SECTION 3:.DESCRIPTION OF PROPOSED WORK-(chick all that applq) • '
New Construction❑ Existing Building jZ Owner-Occupied 0 I Repairs(s) ❑ ( Alteration(s) g... Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Works: F,,(antra bnireone_t. O itP SSCo tsta.to -Wa
off\\ #Q my '` tom' 1S' 0et..s scam Lt 4t a116u3 Ced atAA44-vvvw1
a � arthAi i3 AV to thr, tccot-st , lavtdtn& •
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Estimated Costs: .. .
Item :
(Labor and Materials) OffieiaFTjse Only'' "' '.
1.Building $ :1.Budding Permit Fee-SCOU Indicate how fee.is deteffiined
2q,Out Standard.a City/I'ow$Application pee `' '
'
Electrical $ •
4 . Onn ❑Total Project Cost? tem6)xmultiplier.. • '' x•
3.Plumbing $ 2 OtherFees: $ /J�,
4.Mechanical (HVAC) $ / List • • . •
5.Mechanical (Fire - . .
$
Suppression) / T"otal All Fees:$
ClieckNd.,• . Check Amount • Cash Amount - '
6.Total Project Cost S 33 .000 d paid'm'Full . . la Ot sanding Balance Due:t Q
•
.^ SECTIONS:.CONSTRUCTION SERVICES .
5.1 Construction Supervisor License(CSL)
c�� lDialcg 5-lb-lot
Mix 6erizLJ d . ) else Number Expiration Date
Name of CSL Holder
F Llst CSL Type(see below)
CIO F< c .ld laa
' No. and Street _ Ty±pe� Description
%f„weollt Peat 01a.. Az o1 , (UJ Unrestricted(Buildings up to 35,000 cu.ft)
City/Town,State,ZIP T '
M Restricted I&2 Family Dwelling
M Masonry
RC Roofing Covering •
WS Window and Siding
SF Solid Fuel Burning Appliances
Ipn-3O-9520 LtelatteCCCY}b4 ;(:„ I Insulation
Telephone Email address cirri D Demolition
5.2 Registered Home Improvement Contractor(BIC)
HI
C-T gelodras4nm �, ,1 t+t.1G 14;?-1-1c7�14;?-1-1c7t 2t1�1
C Registration Number E:tpirationDaze
MC Company Name or HI Registrant Name
Ck0 r!'opao(btt(d Livia 1_4flao.( C &etnm�.IA,�
No, d Street Email address
`a rma3� e0M- vvloc 07.1015 t,n 31a A15213
City/Town,State,Z1P Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.§ 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 7a: OWNER AU FLIORIZATION TO BE COMPLETED WAF.N
' ' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize_Cr' (AA, GY40111 &AA, , tete. . Lyt1biked
to act on my behalf in all matters relative to work authorizi:d by this building permit application.
Alh mno,n• ci� otid 419s 1 e
Print Owner's Nathe(Electronic Signature) Date
•
SECTION 7b: OWNER OR AU•1xORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
I yy,nAn be(le.rd (El M iStt , tgtig
Print d per's or Authorized A_nent's Nam atonic Simature) ate
NOTES: •
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(MC)Proomm),will not have access to the arbitration
progmm or guaranty fimd under M.G.L.c. 142A Other important information on the HIC Progam can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eovldos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of hearing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
' _-, r ,= Department oflndustrialAccidents
= 1 Congress Street, Suite 100
✓ •
Boston,MA 02114-2017
`it:.,,,.a1. • www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
• Applicant Information Please Print Legibly
• Name (Business/Organization/Individual): L y& b. (A /„_1 (o M 6041 `tnD
Address: CM) t board 1avl2 "t(` t,a�
City/State/Zip: '']art%oolA �r A, 1w& 0761c Phone#: 101-1 - 51a —Lis-0
•Are you an employer?Cheek the appropriate� box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time).•
7. 0 New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in
anca aci8. .Remodeling
y p rye[No workers'comp.insurance required.]
10 I am a homeowner doing all work myself.[No workers'camp.insurance required.]t 9. ❑Demolition
4.❑I am a homeowner and will be hiring contactors to conduct all work on property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
51,I am sheet.a general contractor and I have hired the sub-contactors listed on the attached 12.❑Plumbing repairs or additions
These sub-contracton have employees and have workers'comp.insurance) 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MOL c. 1 ❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box 41 must also Ell out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such
:Contactors that check this box must attached an additional sheet showing the name df 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 employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: De& i 4tttrex. T IC))ranr e S \%i OS
Policy#or Self-ins.Lic.#: g 4"1 11055 Expiration Date: 4 114119
Job Site Address: 19, Aa oa 1 City/State/Zip:isee 'netQ}{{i. Ma
Attach a copy of the workers' compensation alley
declaration page(showing the policy number an expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pains and
rrennpenalties of perjury that the information provided above is true and cornet
Signature: jy.Qi ►yl �l cJt,
Date: '-tI[g1IS"
Phone#: l 0 1'1—?i la —CAS"ZA
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#:
Oy•YgR a. V . . . . 'S-a_ a. .13u.STH
—y�j BUILDING DEPARTMENT
^� sz' 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261
•
• HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
•
JOB LOCATION:
NAME STREET ADDRESS SECTION OF TOWN
"HOMEOWNER"
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATE ZIP CODE
The current exemption for'Homeowner' was extended to include owner—occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such
homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1)
Definition of Homeowner.
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to
be,a one or two family attached or detached structure assessory to such use and/or farm structures. A person who
constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall
submit to the building official,on a form acceptable to the building official,that he/she shall be responsible for all
such work performed under the building permit. (Section 110 R5.1.3.1)
The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes,by-laws, rules and regulations.
The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes No
If you have checked ves, 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 requiredby
Chapter 142 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 Agent
h:homeownrlicexemp
• • Information and Instructions '
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
• An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
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 employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LISP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space 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 sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. 4 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax 4 617-727-7749
Revised 02-23-15 www.mass.govfdia
o_ TOWN OF YARMOUTH
t.- *— a c BUILDING DEPARTMENT
F ''S 1146 Route 28,South Yarmouth,MA 02664
• S3 1,Ce 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,
[hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 2-e Ammo-. t s3cuA U30-.ST NktimoJksh.010-
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.
JJJQ. th At-ca
Signature of Application Date
Permit No.
•
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Con �truction Supervisor
•
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LYNDA BEDARD _
BOX 27
P.O. ; `.
CUMMAQUID MA 026373 =e . ; Yom ,
Commissioner 051161a=31
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less than 35,C00 cubic feet (991 cubic meters) of
enclosed space.
Failure to possess a current edition of the Mas:-. ,-
State Building Code is cause for revocation of tr:
._.,
DPS Licensing information visit: WWW.MASS.G0 , . .
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= Office of Consumer Affairs & Business Regulation
_ c_vanfia HOME IMPROVEMENT CONTRACTOR
= f= r TYPE: Corporation.
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A�. CERTIFICATE OF LIABILITY INSURANCE DATE
MAD,De"
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 policy(ies)must have ADDITIONAL INSURED provisions or 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 DONIALI
NAME:
Deolivelra Insurance Services LUG Na.FXD. 508.4774023 I iac,No): 508-6384463
800 Falmouth Rd. EIAAIL
UNR101-A ADDRESS: joe@dinsine.com
Mashpee,MA 02649 INSURER(S)AFFORDING COVERAGE NAIC I
INSURER A: Western World-Johnson&Johnson
INSURED INSURER B: A.I.M.MUTUAL
Cape Cod Custom Build Inc. INSURER C:
90 Freeboard Lane INSURER D:
Cummaquld,MA 02637
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 MY 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.
LTRIR TYPE OF INSURANCE ADULDUBR POLICY EFF POLICY EXP
INS!) WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
DAED
CLAIMS-MADE ❑OCCUR PREM SES MsoGE TO cocourmncel $ 100,000
MED EXP(Any one person) § 5,000
A _ NPP1490218 04/14/18 04/14/19 PERSONAL SADV INJURY S 1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY❑ ECT p LOC PRODUCTS-COMP/OP AGO $ 2,000,000
I OTHER: S
AUTOMOBILE LIABILITY (CEOeMeBINEDI SINGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE §
AUTOS ONLY AUTOS ONLY (Per accident)
S
UMBRELLA LAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE S _
DED I RETENTION$ $
WORKERS COMPENSATION PEROTH-
ANDEMPLOYERS'LIABILITY STATUTE I
YIN ER
B OFFICER/ME BER EXCLUDED?ED PROPRIETOR/PARTNER/EXECUTIVE❑ NIA 5011904 04/05/18 04/05/18 EL.EACH ACCIDENT $ 500,000
(Mandatory N NH) EL.DISEASE-EA EMPLOYEE $ 500,000
Ifyee deealbe under
DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS!/VEHICLES(ACORD tetAddNlond Remarks SeMdula;Indy be attached If mom space le required)
LPL r.` AXIbei
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
SUPPLY NEW ENGLAND ACCORDANCE WITH THE POLICY PROVISIONS.
28AARONS WAY
WEST YARMOUTH,MA 02873 AUTHORIZED REPRESENTATIVE
MADISON DEOLIVEIRA
®1988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
• . . •
CAn(MWDO'YYYY)
,azand CERTIFICATE OF LIABILITY INSURANCE
�' 11/16/17
INS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERIIRCATE HOLDER.THS
• CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
REPRESENTATIVEOW. PwA E OF INSURANCE
NSU A CE DOES
O S NOOTTHONS T A CONTRACT BETWEEN THE ISSUING INSURE/KS).AUTHORRED
IMPORTANT: it the certificate holder Is an ADDITIONAL INSURED.the polls: Wes) mist b
mddot� tN d. I certificATION IS ate don d CWAIVED, m theo
an
the terms and cdltons otthe policy,certain pones may rewire an endorsement
certificate holder In lieu of such endorsements).
i-' JOE DEOLIVEIRA 200) 638.6063
D
minces
�'
iveira Insurance Services ' one, (5081 477-3023 Iu24Nd:I
800 Falmouth Rd. '!t St losldinsinc.com
• URIT101-A RI ER%AFFORDIIO COVERAGE I sate•
Naahpse, NA 02649 AAM ,MBA I
Neuro INSURER II:Traveiera I
Jeremy Nickerson INSURER c, I
DHA East Coast Professional MICRO D, -
27 Metoxit RoadIwuRerE, j
East Falmouth, NA 02536 INRIRERF,
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE UBIED BELOW HAVE BEEN ISSUED TO THE INStRED NAME)ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWttHSTANDNO ANY REQUIREMENT,TERM OR CONDITON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHARI THIS
CERTIFICATE MAY BE ISSUED OR MAY FERIAE,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.METE SHOWN MAY HAVE BEEN REDUCED BY PAD CLAMS. _-_• _...., ...._
R{ TYPE OF IN P/Mt !,N WNI FOUL*,Mute* !: i' tSAtS
A +OSAIIRALLusam 1102320110 i 11/23/ill a/saJla: ao'pcToi •5 3.000.000
I X'CCAMErCUKoEneMLLRSLrc r PRUIRSET RENTED
• 500.000
CLARAEAAADE _A_OCCURI i :ACD Y]PWY'ens parson) s 10.000
' 1 PERSOIRLSAOVINURV $ 1.000.000
•
' • AGGREGATE .GREGATE .a 3.000.000
-••i I i PRODUCTS•COIRP?P AOC iS 2.000.000
`GE�N'LAOGAEMnIRRMppIT.APP�@S PER .
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CARPENTRY 3 STORIES OR LESS
JEREMY NICEERSON EAS ELECTED TO EE COVERED UNDER THIS 1IOREERS COMPENSATION POLICY
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFF TIE ABOVE DESCRIBED POLICIs BE CANCELLED BEFORE
TIC EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED N
CAPE COD CUSTOM BUILDING INC ACCORDANCE WITH THE POLICY PROVISIONS.
- PO Box 27
' Cummaquid, 1A 02637 AUTHMD®REPI@SENTATNE
ANAHDA ELDRIDOB
®1888.2010 ACORD CORPORATION. All rights reserved.
AMR I)2S(2010/05) The AC ORD name and logo are reglatomd marks of no RD
Phone: (617) 312-4520 Fax E-Mall: BEGET!LIVE.COM
CAS --Ve Farlechov,
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• at X" TOWN OF YARMOUTH
.Ctto HEALTH DEPARTMENT
• �\'^�•%� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 24 PaCnns vicui t 0e/fly Nkurrno0W, (wk.
Proposed Improvement: E xea ttd c6.,--f 6.1-1-Canto pf-kle oPaci . X5:1444 Cr% i-lne otrefal\
S\-rt)oh)t e toy ' '^ 1 �! 1B'. Is.l°uJ `fat_ 1.nAl cash allot) RV 01 ore
'bin)fas8 e.InnaP ntrAn.3 t_.1 Awl ,frn4J_ t.Ol'+ t latld fl. .
Applicant: L. r,r1n, P- eAeAvA : &t pe art ClismIrnfat i t(d :St Tel.No.: 1p 1"l-,?11,
Address: A o Frezlorn ( lata •ieurrttooklneof-l- rvla 622n5 Date Filed: •
•*Ifyou would like e-mail notification of sign off please provide e-mail address: L vada e cc (t y,4-t mle i td ,(cYYI
Owner Name: t op P t Ni 1MP_LO (an\,p,na : NA-WI bay (o t r'a rt .
Owner Address: It-5 East e'C22T Owner Tel.No.: 50,6 -3,,3a 5555
X 1tOW
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: ( 001 DATE: D �'-C17
PLEASE NOTE
COMMENTS/CONDITIONS: /
MGL AND FIRE
,4040/14.- TOWN OF YARMOUTH
as, ' ) REVIEWED FOR CODE COMPLIANCE.
• 4: :1,011) / ERRORS OR OMMISSIONS DO NOT RELIEVE
THE APPLICANT FROM THE RESPONSIBILITY
OF"AS BUILT"COMPLIANCE.
DATE: q-ao-($
r fin . ICc I/ /n1j4ciC.1;
YARMOUTH FIRE PREVENTION INSPECTOR 7_1-4—
Commercial Construction Building Transmittal
Project Name: Supply New England Address: 28 Aarons Way
Contact Name: Linda Bedard Phone: 617-312-4520
Y NO NA Subject Regulation
E
S
X Access for Fire Apparatus 527 CMR I; 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
X *Service Stations 527 CMR I ;16.2.3,16.2.3.1,30.3.2
X *Hazardous Materials Storage 527 CMR I;60.1
X *Kitchen Exhaust Systems* 780 CMR,527 I;50.1
X Extinguishers 527 CMR 1; 13.6,Chapter 148;sec 28
X Fire Alarm Systems/CO detection* 780 CMR,Chapter 148;,527 CMR l; 13.7
X *LPG Storage Chapter 148;sec 9,10,28&527 CMR 1;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.
The YFD supports the application, subject to applicable submissions, permits and
inspections.
Description of planned project/other requirements: Extend office space
Plan Reviewed By: Captain/Inspector Nevin Nadi Date: 07-20-2018
Copy for Applicant [ 1 Copy to Building Department II Copy to Fire Prevention
Entered in Firehouse 0 Final Inspection
• Sears, Tim
From: Sekrs Tim
Sent Wrd esday,July 25, 2018 9:08 AM
To: 'ly d @cccustombuild.com'
Subject: 2 A ron'IsI Way
Attachments: Ex sti g quilding checklist 2015.docx
Lynda,
I have reviewed your application for 28 Aarons Way and we are going to need more information to complete your
application;
1. Construction Control affidavits
2. Existing building evaluation from architect(Section 104.2.2.1)
3. Attached form completed by architect and returned
4. Sprinkler alteration plan stamped by fire protection engineer
Please submit these items for review.
Thank you
Timothy Sears 030
Building Inspector
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsears@varmouth.ma.us
1
. but) DC Cop//
TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02 64 i_ C E ] V E P7
508-398-2231 ext. 1261 Fax 508-398-08 6
Office of the Building Commissioner L AUG 13 2018
BUILDING DEPAHTM_�NT
By
Massachusetts Existing Building Code Checklist
, Based on 2015 IEBC w/Massachusetts Amendments
To be submitted with Building Permit Application
Address:, ,4AZt31J.5 Wit `j'4ejj Y/t,Q,4i4U MA
(Street number,name) (Cityfrown)
Unit Suite(location within building)
Risk Category: (Check one), 0 Risk Category I, (f Risk Category II, 0 RC III, 0 RC IV.
/ t
Work proposed: % JAIL cos L e_: ' r'r its Jr _ X/5
fr 1AreNr .:i.'f ed/ r
4/1 � P eG r D1/t_—.2" A
Construction Control,building at 35,000 c.f.or greaterg Yes 0 No
If Yes then"Investigation& Evaluation Report"is required(780 CMR 34,104.2.2.1.)
Compliance Method: [Only one method to be used] (Check all boxes that apply)
Prescriptive Work area Performance
(Chapter 4) (Chapters 5—13) (Chapter 14)
❑ Repairs 0 Repairs:Chapter 5 0 Repairs
Alteration 0 Alteration:(check only one box) 0 Alteration
❑ Addition 0 Level 1: Chapter 7 0 Addition
❑ Change of Occupancy 0 Level 2: Chapter 7&8 0 Change of Occupancy
O Level 3: Chapter 7, 8&9
❑ Change of Occupancy: Chapter 10
❑ Additions: Chapter 11
❑ Historic Buildings:Chapter 12
❑ Relocated or Moved Buildings: Chapter 13
Note: Chapter 15 applies to all compliance methods.
Applicant's Name:(print)
Signature: Date:
• Initial Construction Control Document
I if/ To be submitted with the building permit application by a
E.�y Registered Design Professional
•
for work per the ninth edition of the
..,mia Massachusetts State Building Code, 780 CMR,Section 107
Project Title: Date: /W. 42 7t9/eS
4L7 f97P4i3 —.*r,CG�✓Neilatic-444,12
Property Address:
a ,tsf62 4/— if/MV, r Y tegoz977/
Project Check(x)one or both as applicable: New construction L Existing Construction X
Project description: EXPdrtl9 4'/ lit,CS, To /41" aCE /sX/r�ifcs,
sZWaVR.v v €,w, r72' W ,c '/Ilni aafithe . 4'?_
I 4 MA Registration Numberj2V2Expiration date ram a registered design professional,and I have
prepared or directly supervised the preparation of all desiggnn�,lans,computations and specifications concerningl:
Architectural X Structural X Mechanical
Fire Protection Electrical Other.
for the above named project and that to the best of my knowledge, information, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780
CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my
designee)shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building officiaL
Upon completion of the work,I shall submit toahiel .C _ official a'Final Construction Control Document'.
Enter in the space to the right a"wet" or taaosz�. p ,
electronic signature and seal ""` e n �/'
ut 1 ' v
Phone number;543u,Z—41,84 Email: ,,OSS44.5teheLpw/ 7'.1/67
Building Official Use Only
Building Official Name Permit No. Date.
Note 1.Indicate with an'x'project design plans,computations and specifications that you prepared or directly supervised.If'other'is
chosen,provide a description.
Version 01 OI 2018
C-
it
Stephen R.Nelson Associates
Architects
129 Bank Street
Attleboro,MA 02703
508-222-0821
Fax 508-222-2455
Nelsons89@comcast.net
August 6,2018
Mr.Timothy Sears CBO
Building Inspector
Town of Yarmouth
1146 Route 28
South Yarmouth,MA 02664
Dear Mr.Sears;
The following is Building Investigation and Evaluation in accordance with Chapter 34 section 104.2.2.1
The building to be altered is located at 28 Aaron's Way in West Yarmouth.The total area of the existing
building is 9,846 SF.The building is one story with a mezzanine over the 1,200 SF office area.The area to
be altered is approximately 15 ft x 15 ft.This area will become part of the office area.This area will have
a mezzanine over.A new stair will be built to access the mezzanine.This will replace the ladder currently
being used to access the mezzanine.The Use Groups for the Building are S-1 Storage and B Business.The
construction type is Ill B.No separation is required between use groups B,F-1,S-1 and M.The building
has a sprinkler system.
Section 104.2.2.1
1.Structural-The new mezzanine over the expanded office area will have a live load capacity of 125
PSF.The beam to replace the section of wall that is being removed is designed to carry the load from the
existing mezzanine.There are no other structural changes.
2.Means of Egress-There are no changes to the means of egress except that the warehouse section
will now go through the expanded office area.An illuminated exit sign will be placed at the warehouse
side of new door#1.
3.Fire Protection-The existing sprinkler system will be modified to provide proper coverage at the
expanded office area and mezzanine.
4.Energy Conservation-There will be no change to the exterior envelope.
5.The lighting for the expanded office area will comply with the code.
6.Hazardous Materials-No hazardous materials are involved with the alterations
7.Accessibility-The space being altered will be accessible.
8.Ventilation-The added office space will be connected to the existing HVAC unit.
The compliance method for the project will be Prescriptive Chapter 4 Alterations.
403.1 All new construction shall conform to the 2015 IBC with Massachusetts Amendments.The
alterations shall be such that the existing building will be no less conforming than the existing building
was prior to the alteration.
403.2 NA(not applicable)
403.3 No change gravity load carrying structural elements except where a section of wall is removed.A
new load carrying beam will be installed where the wall is removed.The live load capacity of the
k
mezzanines will be posted.The concrete slab has been analyzed and can carry the new toads from the
mezzanine.
403.4 No increase to the design lateral loads.
403.5 Thru 403.11 NA
All work and methods will conform to Chapter 15 of the 2015 IEBC.
Sincere
lay— A a..N..............
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RECEIVED
SUPPLY NE AUG 23 2018
28 AARONS WAY
BUILDING DEPARTMENT
YARMOUTH, MA eY: —
Fire Protection Narrative Report
Introduction
Supply NE is an existing warehouse/retail supply building.The current
office-showroom area requires customers to enter the warehouse portion of
the building to gain access to the showroom/retail desk. This modification
will extend the office (15' x 15') so that customers directly enter the
showroom retail area.
The building has an existing wet pipe sprinkler system and is fully
sprinklered. This modification will add a small 225 sq. ft. addition to the
office and storage mezzanine above. The roof level sprinklers protecting the
storage on the mezzanine will be not be affected. The additional sprinkler
heads will consist of four(4)chrome pendent sprinklers below the ceiling and
four (4) special application sprinklers in the combustible concealed space
above the ceiling. The additional heads for the office extension will be
supplied by the existing 4"wet system feed main and 2 '/z"drop to the existing
office.
901.7.1.1 (l.a) Basis of Design
Section 1 Building Description
a)The building is classified as Moderate Hazard Factory (S1)structure as
defined by 780 CMR.
b)The new office extension is 225 sq f.
c)The building height is approximately 20' above grade elevation at the roof.
d)The building is 1 story above grade.
e) The building is 0 stories below grade.
f)The buildings are of Type II construction.
g)The building is occupied for warehouse/contractor retail supply.
Section 2 Building and site Access 901.7.1.1(2)
a) The Fire Department has vehicle access to three sides of the building and foot
access to all four sides.
' Section 3-Applicable Laws, Regulations, and Standards.
The following are the governing codes for this construction project:
a)780 CMR,The Massachusetts State Building Code, 8th Edition,Chapter 9,Eke
Protection Systems.
b) NFPA 13,2016
NFPA25,2017 '
c)M.G.L,Chapter 148
d)527 CMR Fire Prevention Regulations
e)Specialized Codes—Not Applicable
t)Town of Yarmouth By-Laws
g)Other State or Federal Laws-Not Applicable
Section 4-Design Responsibility for Fire Sprinkler Protection System
A. P. Caputo,P.E.
Pyrotech Consultants,Inc.
2 Washington Circle,Unit 5
Sandwich, MA 02563
Section 5 -Fire Protection Systems to be Installed
Fire Hydrants and Water Supply 901.7.1.1(3)
a)Site hydrant(s)Not Applicable
b)Location and size of public water mains
• The building sprinkler system is fed from an existing city main
located on Aarons Way.
c) Location and size of private fire service main. Existing 6"DI service
connection installed into building from Aarons Way.
• Page2
•
A
Sprinkler System 901.7.1.1(4-8)
a) The office addiiicn will be pnttalwithK 5.6,155-degree sçtinlderheads installed
above and below theoficedroppedceiling.Theheadswiillbesupplieedbyadecfic i '
feedmain and 1'/"branch lines.The existing warehouse building sprinkler
system has been hydraulically designed in accordance with NFPA Stan d
13 to provide a minimum design density of 0.2 gallons per minute(gpm)
per square foot(sf)over the most remote 1500 sf.,with an additional
250gpm allotted for fire department manual hose streams. The heads wil
be fed from an existing roof level 4" feed main and 2 '/s" from which a
new 2" main will run down to a new 1 'W branch lines. The following
will be provided:
• New 2" main to feed the sprinklers as shown on Pyrotech Drawing sheet_
Engineers Stamp date 8/23/18.
• Quick-response K 5.6,pendent sprinklers and K 5.6 special application
upright sprinkler in the combustible concealed apace above the dropped
ceiling.
b)Main control valves serving the sprinkler system is located in the
See Environmental Fire Protection Sprinkler drawing"SP-1"dated 8/1806.
Fire Alarm and Detection 901.7.1.1 (9-10,13)
An existing fire alarm system is provided. The new sprinkler heads and
piping will have no adverse effect on the system.
Carbon Monoxide Alarms 901.7.1.1(21)
Not Applicable
Alarm Supervisory System 901.7.1.1 (18)
Existing
Fire Extinguishers
Existing by others.
Fire Extinguishing Systems 901.7.1.1(14-15)
Not Applicable
Page3
i , %
•
Smoke Control/Management Systems 9 01 .7. 1 . 1 (11-
12)Not Applicable
Auxiliary Life Safety Systems 901 .7. 1 . 1
(13)Not Applicable
Fire Command Center 901.7.1.1(19)
Not Applicable
Emergency Power Systems
Not applicable to fire sprinkler system
Section 6-Features Used i n the Design Methodology
The structure is currently protected throughout with a wet pipe automatic sprinkler
system. The addition ofthe office designed in accordance with NFPA Standard 13
requirements and hydraulic pipe sizing ofthe existing office area system.
• Page4
.
4 IS
901.7.1.1 (lb.)Sequence of Operation
a) Specific device operation sequence
• Tamper Switches-Tamper switches are located on the building's
main sprinkler riser control. If a valve is improperly closed,a signal is
sent to the FACP.
• Flow Switches-Flow switches are located on the building's sprinkler wet
system. The fusing of any one wet system sprinkler will allow for water
flow from that sprinkler or any additional fused sprinklers.A signal is
sent to the FACP resulting in an alarm of fire signal throughout the
building and to a central station monitoring facility and/or fire
department.
• Sprinkler-The sprinkler shall activate when a sprinkler is heated,due to
a fire condition,to the temperature of the sprinkler's fusible glass
element,the glass element will break. The pipe-cap and sealing spring
assembly in the orifice,normally held in place by the fusible glass
element,will be pushed out of the orifice by the water in the sprinkler
piping. The water flowing through the sprinkler orifice strikes the
sprinkler deflector,forming a uniform spray pattern to extinguish or
control the fire.
b) Sequence of Operation of the Complete Fire Protection system.
• All control valves are monitored by the building FACP via tamper
switches.Closing of any of the valves will activate the switch causing a
local supervisory signal at the FACP and transmission of a valve closure
alarm to the commercial central monitoring station.
• Page5
' S
901.7.1.1 (1c.) Testing Criteria
Section 1 Testing Criteria
Personnel
• Coordination,scheduling,personnel and equipment will be
performed/provided by fire sprinkler contractor.The Owner's Rep will assist
in the scheduling of testing/inspections with the Yarmouth Fire Department,
Section 2 Equipment and Tools
• The following equipment shall be on hand for the testing of the Fire
Protection Sprinkler System:
• Manufacturer's Instructions for:
a.Flow Switch's
b.Tamper Switch
c.Supervisory Pressure Switch's
d. Sprinklers
• Gauges
Section 1 Testing Criteria and Methods
• All testing to be in accordance with NFPA 13,NFPA 25, applicable
sections of NFPA 72,and manufacturer's requirements.
• The newabove ground piping will be hydrostatically tested to 200 psi for
two hours.
• Main Drain and Inspector's Alarm Flow Tests will be conducted for the
systems..
• Control valve tamper switch closure tests will also be conducted.
• A Contractor's Certificate for Above Ground Piping will be required.
— Page6
1 •
I " 6
Section 2 Testing Schedule
a) List the personnel responsible to schedule and coordinate the testing of each
system and the interconnection between systems
Fire Sprinkler Contractor& Cape Cod Custom Build,Inc.
b) The schedule of testing. Test dates to be determined
SECTION 3 Approvals
a) List the approvals by the contractors,designer/engineer of record,and Fire
Department
Test certificates in accordance with NFPA Standards
1. Above ground test certificates will be provided by the installing
contractors.
Test certificates in accordance with manufacturer's specifications
1. Equipment shall be inspected and tested in accordance with
the manufacturer's installation instructions.
b) List the documentation required for each test,the reports required and
distribution
Signed certificates by installer
1. The fire sprinkler contractor to submit a certificate stating that the
system has been installed in accordance with the approved plans,
specifications,and submittals,and all subsequent revisions thereto,and
all applicable codes and regulations.
•
— Page?