HomeMy WebLinkAboutBLD-19-1494 #1 •
of•yet — BUILDING BUILDING PERMIT APPLICATION
• (tZ 'r APPLICATION TO CONSTRUCT,REPAIR.RENOVATE,CHANGE THE USE,OCCUPANCY OF,
C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Cr• •�.-��. a Z. Town of Yarmouth Building Department
%):Lim.,••^S 1146 Route 28 . Yarmouth, MA 02664-1492
Tel: 508-398-2231 ext. Fax 508-39&0836
Office Use Only,�t/g!/ Planning Board Information Assessors Department Information:
Permit No.,�LS l9" lyaCe'T Plan Type Map Lot
Permit Fee $ Endorsement Date 31/ N/
Recording Date New
Deposit Recd. $861.) Date_ Plan No. 1.4 Property Dimensions:
Net Due $ Other Lot Area(sf) Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number. Data Issued:
Signature: . -'—k . / Certificate of Occupancy
Building O cial Date is Is not required
Section 1 - Site Information
1.1 Property Address: /74 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(M.O.L C.4e.S 54) 1.5 Flood Zone Intonation: Comments
Public Private Zone: BEE
( } \CS�ectio�n2--PProperty Ownership/Authorized Agent
2.1\\1� �Owner\fiReeoed: •
fir yoye iprint) Mailing Address:
p
Signature Telephone Telephone Email Address:
2.2 Authorized Agent
R0,4)\\\\..1?h\p,kGrA Qoya,r1 cthCAM, cvsr
Name(print) Mailing Address:
41
Signature Telephone Fax Emlail dre,5
Section 3 -Construction Services •
3.1 Licensed Construction Supervisor Not Applicable 1J
cut\ \ \‘.Pt4kciO,‘N.
\ \ License Number
Address CS$j 115
a — AMU . . Expiration Date
i tura elephone Email Address: *AM
1 of 4 OVER
•
3.2 Registered Home Improvement Contractor. •
-Company Name Not Applicable
a
\` t
Address Rf aron Icriber
Ic pt p81 (Ckt`PcS\\R
w . m_ A(e2:t Ex irar \Ellaate •
Signature / _ Ilephone cog-21,'0`iz0 11\1 Sr\
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
Name
Address Registration Number
Signature Telephone Expiration Date
Area of ResponsibilityName
•
Address Registration Number
Signature Telephone Expiration Date
Area of Responsibility
Name
Address Registration Number
Signature Telephone Expiration Date
Name \ Area of Responsibility
•
Address Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor
\Z,U1‘1 .1\ ACrtan. Not Applicable ❑
C pa y Norte
\ct)'(V' 1 b j\ IrCi-n^
Per��sppn ResponsibW for Construction
Addresses YA_2 Pitt y4\
Signature Telephone ,rA J
2 of 4
, Section 6- Desgrion.u Proposed Work(check all applicable) -
New Construction ❑ (tor multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms
it• • Existing Bldg. ❑ Repair(s) ❑ Alterations
❑ Addition ❑
Accessory Bldg. 9 Type Demolition Other Specify:
" AccDescription of Proposed Work: (t ` ,.I',
1114
Ir\\ \iAf c{5 -0 P N XA ts(\ COW toar\kAto ✓
Section 7- Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑
A-4 ❑ A-5 ❑ 1B ❑
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ 28 ❑
F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD ❑ 3.4 ❑
I INSTITUTIONAL ❑ I.1 ❑ 1-2 ❑ 1-3 9 38 ❑
M MERCHANTILE ❑ 4 ❑
• R RESIDENTIAL i❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
5 STORAGE ❑ s-1 CI 5-2 9 58 ❑ .
U UTILITY ❑ SPECIFY: •
M MIXED USE ❑ SPECIFY:
5 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(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 (7B0CMR 110 11) e
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, -1-nf a,cr4_li-I;, C C c_-. •}\ $(\\` , as Owner of the subject property.
hereby authorize to act on
my behalf, in all matters to work authorized by this building permit a plicatio .
Signature of Owner Date
3 of 4 OVER
l •
SECTION(� )•'I'11.d\\, 10b OWNER/AUTHORIZED AGENT DECLARATION
I, u \\tlA,c,(M , 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.
\Zulu\\ \ ziGo •
Print Name
VA��lf�
Signature of Owner/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
jo psn at)
2.Electrical
3.Plumbing/Gas
•
4.Mechanical(HVAC)
5.Fire Protection
e.Total e(1 a 2.3+4♦5)
7.Total Square Ft.go-new sexton&.d e)
Check Below
U Conservation-Commission Filing
(if applicable)
•
U Old Kings Highway&Historical
Commission approval
(if applicable)
•
4 of 4
•
•
� 't. The Commonwealth of Massachusetts
Department of Industrial Accidents
• _ _= Office of Investigations
_f.t=.
.600 Washington Street •
'=� `` Boston,MA 02111
aims.* •www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individoal): VsitaA \t.1 (C7i)A
Address: 20 'm. ku
City/State/Zi.: yak ►' OZl Phone#: : - . • - a 0
Are you an employer?Check the appropriate box:
4. Type of project(required):
I.❑ I am a employer with ❑ I am a g eneral contractor and I
s/employees (frill and/or part-time).* have hired the sub-contractors . 6. ❑New construction
2. I am a sole proprietor or partner- lilted 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 . 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL
12.0 goof 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'w
mpmsatmoa`pohts 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.
:Contractors that check this box must attached an e,iriirinnal 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 thea 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct
Sienature:.-12 Date: WO
Phone#: "CM-2130 -1,.ay() ,
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 Instruction .
Massachusetts General Laws chapter 152 requies•all employdrs to provide workers'compensation for their=civets:"
t.
Pursuant to this statute,an employee is defined as"_.every person in the service of another under any contact of hire,
express or implied,on1 or written."
An earpigr is defined as"an individual,partnership,association,corporation at other legal entity,or any two
or more
of the foregoing engaged in a joint enterprise,and including cher 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 Incas having not more than three aputaseisis and who resides therein,re the occupant of the
dwelling house of another who employs persona to do maintenance,construction or repair work on such dwelling house
• or on the grounds or building sppurtenent thereto shall not because of such employment be deemed to be an employes"
MGL chapter 152,§25C(6)also stats that"every state or heel licenses agency shall withhold the haunts or
renewal oft license or permit to operate a bestial or to construct baildlap In the commonwealth for any
applicant who has not produced acceptable crickets of compliance with the Imamate coverage required
Atmit arwily,MGL chapter 152, 125C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perform:me 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'coavpensatsan affidavit completely,by checking the boxes that apply to yotr situation and,if
necessary,supply sub-contractor®name(s),address(es)and phone number(s)along with their certiseate(a)of
insurance. Limited Liability Company(LLC)a Limited Liability Parmenhipe(LLP)with no employees other than the
membra or partners,are not required to carry workers'compensation insurance If an LLC or LLP does ban
-employees,a policy is required. Be advised that thio affidavit may be submitted to the Department of Industrial
' Accidents for conformation of i M"a"r"coverage. Abs be awe to sip and date the affidavit. The affidavit should
be retuned to the city or town that the application for the permit or license is being requested,net 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 Departures at the number listed below. Self-insured corrpsnies should enter their
self-iasormos license mumbo on the appropriate lino
City or Town Ofndatr
Please be sure that the affidavit is complete and printed legibly. The Department has provided i space at the bourn
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 subnit multiple pantie icense applications in any given year,need only submit ore affidavit indicating current
policy information(if necessary)and under lob 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 oe licenses. A new affidavit nut be filled out each
year.Where a home owner or ciders is obtaining a license at permit not related to any business or commercial ventre
(Le.a dog license or permit to berm learn 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 to a call.
the Department's address,telephone and fax manta:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investiptlons
• 600 Washington Stmt
Boston,MA 02111
Tel. 11617-7274900 ext 406 or I-877-MASSAFE.
Fax it 617-727-7749
Revised 11-22-06 www.mass.gov/dia .
-- _- - t ogYa TOWN-OF-YARMOUTH — —
o$_� e � r BUILDING DEPARTMENT
• f °� 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 I, Section 1115,
[hereby certify that the debris resulting from the proposed work/demolition to be
conducted at —1\\ Q ke7g) C A60.4\Vktn. 0?— apt{
Work Address
Is to be disposed of at the following location: 0-S 4,I(dAr1( (9.
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
2Ni0
Signature of Application Date
Permit No.
r ,
ot_YAe TOWN OF YARMOUTH
• ^F' 0
HEALTH DEPARTMENT
3
C.•�/ PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 111 Rot& 2t cL'AustrothqjS. IAA. 0t4N-\ Ker I
Propose Improvement: bp.k C \ ., ♦ N
Applicant:%AI% .t6.)V\
Tel.No.: 500-2/0 -(02116
Address: i‘o�0t �h CsiYt\t)V`\\t. JWA, 024t2,2_, Date Filed: gig it
"If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: %&(-"\\ ,� \ \n
Owner Address: VIC\ E Ze 1GA. Orl\EXA )vA. 0.(,5 Owner Tel.No.:.566-2m-u$qi
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: ^\-71-r/ DATE: 7/CAV
PLEASE NOTE
COMMENTS/CONDITIONS:
MGL AND FIRE
• f3144104TOWN OF YARMOUTH
REVIEWED FOR CODE COMPLIANCE.
'1 4:� ERRORS OR OMMISSIONS DO NOT RELIEVE
* �� THE APPLICANT FROM THE RESPONSIBILITY
OF'AS BU r OMPLIANCE.
N DATE: C' 6 le I
YARMOUTH FIRE PREVENTION I PECTO
Commercial Construction Building Transmittal
Project Name: Pier 7 Address: 711 Route 28
Contact Name: Randall Henderson Phone: 508-280-6240
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 1;22.3
x *Service Stations 527 CMR 1 ;16.2.3,16.2.3.1,30.3.2
x *Hazardous Materials Storage 527 CMR 1;60.1
x *Kitchen Exhaust Systems* 780 CMR,527 1;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 I; 13.7
x *LPG Storage Chapter 148;sec 9,10,28&527 CMR 1;69.1
Use and Occupancy(FH Building Class) 780 CMR;302.1
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
*Upholstery 527 CMR I;20.6.2.5
*Trash Containers 527 CMR I; 19.1.1, 1.12
x Any Hazard to the Public Chapter 148;sec 28
*Curtains,Draperies, Blinds 527 CMR I; 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: Bathroom Remodels only not
affecting fire alarm system/sprinkler system
Plan Reviewed By: Lieutenant/Inspector Scott a.Smith Date: 9/6/2018
Copy for Applicant 0 Copy to Building Department Copy to Fire Prevention
Entered in Firehouse n Final Inspection
n__X J
/ 96" / x 8�° i.
. Fe 18 o ,LL
$moo
Al2" , 31 Z " / 22136" /131r / 16" / =s 9
Qooz
r .N5
/ 24" / 72" / o s o T ...iz mom lt
Ce Cn CD
(� m
O 0 re� V i
\ IX
� — Wu-
/ N
< art
O _ j i �-
i- IMP OO CO �-
N N F y (VMBWTR I -Io
TOIL.WELLWORTH D I
O ____Y \roO
_ o
d' a) EEC �MD X CO
SLP 062018 E O
1
ri
HEALTH DEPT. 7
J
N. N. \ ....‘.....a
NN NN
All dimensions size designations This is an original design and must Designed: 8/1/2018
given are subject to verification on not be released or copied unless Printed: 8/3/2018 :,
job site and adjustment to fit job applicable fee has been paid or job
conditions. 1 L order placed.
PEIR 7 CONDO BATHS All Drawing#: 1 No Scale.
- mamm • • mommliglimmomm Mille11111.
_NNW Mann MENNMENNMENNENNN • MOM
'_ EMMIIMMIM &MEM T _ l____ _1_111.1 II
1111111111,111111 I 1111 q_ .
- Wiiir '''''''' ' ' Ira yi
MIMIMM ME MEM AIM MAI NM • t,:
111111 11 III t4' 111
WWI III. —
. 1 I I - : ;
9„ oe a
lilf
EEME
AIIIIIII III
__ ___ _ __
I-
____
1 1
1 _I LlI , -I-t _.]
I._ goxa
I 1•
i I
• I 1_ u I _l_ . 08." • -
I- F
1
__IL t.2 1
I I 1 7 - 1 _1 -II
I il J _, _
_1 I I i 1 1
IL- 11 1 -::. Hi I ' HH 11_ I I
I 1 1 ! - i 1 1 1 , I is ,-
lli
c.., , . _1 , , _ 1 I r. , , , k I
1 I F 1 ; - ' I I I 1 1 1 1 I ; 1
1 1 I 1 1 tzio 1 . , I ] -1 5_,,71 1 i 1 I —I- 1 . —
! 1 I 1 I Li . 1 _ 1 t _1 1 I 1 1 L_ I . 1 1
1111 _ 111 ,LT _Hi III I
_ HI 1 - I ! ILI _ 11111 _11 _ 1 ' 11 I I -1-_,,c_
111111 . 1 1 1, 3, r_. 1 1 1 ..ii I 1 I 1 — 1- 1-1 -
iIi
II
II HiLliiii 141 ! II jj 1 1 • 1
1 1 i 1 1 1 I 1 1 1 I 4oidsoL1 i I 1 1 I , IT i
II ' II _1 -1- 111111r1 .1 _ 11 —. 1 11 . I 1L. I
1 1 ! 111i1111 I iI-
1: 1 . 1
1 " 1 ! II I 1
.111 I 1 1111 _
11 111 , k I
I 1
1
j-
, _
1 • 1 . 1
I 111 ill ii I IIT ---11