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HomeMy WebLinkAboutBLD-19-1497 #2 of•rqR BUILDING PERMIT APPLICATION 2e S APPUCATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, • • t ; + OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING: • 1'' E• J�wn�c�� . Town of Yarmouth Building Department a�. 2' `�\!" "' 1146 Route 28 . Yarmouth, MA 02664-4492 Tel: 508.398-2231 ext. 1261 Fax 508-398-0836 _ �{� ]� Vice Use D ly Planning Board Information Assessors Department Information P`e'rrlfif 100. if—O l to_ Plan Type Map tot Permit Fee $ Endorsement Date F -" //,‘ Recording Date New Deposit Redd. $ Date_ plan No. 1.4 Property Dimensions: Net Due $ Other Lot Area(sr) Frontage(It) Lot Coverage This Section for Office Use Only Building Permit Number. ' Date Issued: Signature: —4,----- 7 5 -/D -,I Certificate of Occupancy Building Official Date is Is not required Section 1 - Site Information 1.1 Property Address: n 1.2 Zoning Information: %&1'b S�itncWU. 1 , / /' VI\elY,* L 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(MAL c.40.S 54) 1.5 Flood Zone Intormafon: Comments Public Private Zone: BEE • • Section 2- Property Ownership/Authorized Agent 2.1 Owner Record: 0. a RS t�;� ^ �n t•S--nY J"aS,‹ Mailing Address: J Signature Telephone Telephone Email Address: 1 2.2 Authorized Agent: 9 oc1\11)\\Sok t\.ect nA Q') \ `l i ?'cch11 q., ), •s7,7 Hams(print) Mailing Address: `` Signature Telephone Fax Email Address: i ISection 3 -Construction Services I 3.1 Licensed Construction Supervisor. Not Applicable ❑ I CweAt\\ \ E 4(110n f I ‘0\)0 \%"\ C`^""`\}V? `A OZ 17)7 License Number Address [•S-6j r f� hU "2j` SUV .fit»tuie Q\khoozzoi Expiration Date I t lure Telephone Email Address: 1\\3u`\'o I _.._..__...__ .- __ .-.-- _ _.--. __.,___ Section 6- Descrion.d Proposed Work(check an applicable)] - New Construction ❑ (for 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: ; 1 \ (� ` . t t; . ^:i(79Mn T rni )e\r c o1A'i 1 Ct YJI(P et-it t ' *P LY-I t1fm11(4 Pt\\ - `CeMslAkA t �[LVre t.()CIAkX\S 7_ Section 7- Use Group and Construction Type Building Use Group(Check as appricapable) Construction Type • A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ _ A-4 ❑ A-5 ❑ 1B ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL ❑ 29 ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL 0 I-1 0 1-2 ❑ 1-3 ❑ 30 ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-I ❑ R-2 ❑ R-3 ❑ SA ❑ S STORAGE ❑ 5-1 ❑ 5-2 ❑ SB ❑ U UTILITY ❑ _ SPECIFY: M MIXED USE 0 _ SPECIFY: S SPECIAL USE l] 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 (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required dYes .... No SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT • ca,-TN- :+r\<j Qv.-- • th`2IQ , as Owner of the subject property, hereby authorize \ to act on my behalf, In all matters relat* to work authorized by this building permit a plicatio . Signature of Owner Date • 3 of 4 OVER ! w • SECTION 1N1 0b OW �`N `ER/AUTHORIZED AGENT DECLARATION I, \`����,\ �FtMl$ke-04 ,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 0))1fi - Signature of Owner/Agent Date Section 11 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2.Electrical 1 o tsrO 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection 5.Total.(1+2.3+4+5) 7.Total Square Ft Mr n•*wean I Who* Check Below ❑ Conservation-Commission Filing (if applicable) • ❑ Old Kings Highway&Historical Commission approval (if applicable) • m• 4 01 4 a Lta*I . The Commonwealth of Massachusetts Department ofIndustrial Accidents,. • v _Iti _.i'•--- Office of Investigations —gid= - t= 600 Washington Street • •.: ;n �9t_ iv � Boston,MA 02111 .k '�` •wwwmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): \\ ‘40(SPA Address: Qp tit 4).1 City/State/Zia: ys; t. 00 Phone#: ' — i I —O. 0 Are yon an employer?Check the appropriate box: 1.❑ 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. 0 New construction 2.1M I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub-contactors 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 area corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their . 11.0Plumbingr right exemption per MGL or additions myself [No workers'comp, rit of p insurancerequired.]t c. 152, §1(4), and we have no 12.0 Roof repairs - 3a.❑ I am a homeowner acting as a employees.[No workers' 13.0 Other • general contractor(refer to#4) c comp.insurance required.j. - 'Any applicant that checks box irl must also fill out the section below showing their workers'compeosatioa`policy information. t Homeowner who submit this affidavit bp-9ring they are doing all work and then hire outside contractors 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-contactors have employees,they must provide their workers' policy comp.p n®bec 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/Zlp: 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 paint and penalties of perjury that the information provided abovev� is true and correct • Signattrre:� �Z� Date: � fv • Phone#: T\I)9r24b 'f dl-1() . Official use only. Do not write in this area, to be completed by city or town ofciaL 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#: - -- °`="4 t-- '-1'OWNN-OF—YARMOUTH-- - ---- I o - . r.�� BUILDING DEPARTMENT 1146 Route 28,South Yarmouth,MA 02664 gra 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 1115, [hereby certify that the debris resulting from the proposed work/demolition to be conducted at I\\ Qc&t\e?Q c..)>V tM yi . ozuoti Work Address Is to be disposed of at the following location: 07, (1,1(40i1/41 (I). Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 01P0 Signature of Application Date Permit No. r oto Aey TOWN OF YARMOUTH =_y,� - HEALTH DEPARTMENT Fes _ ;r `'' �_••% PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: n Building Site Location: III Race 2? S. W' mv"4 3 1: oL-L Gy ( kr 1 ProposecjImprovement: ve0 i ft. 's,, ; r► JJQ\.l Svk%Ml'7 cxtt3, as \ ). Applicant:W\eik% l),r14.1, Tel.No.: X00—Z O -(210 Address: \Abt �`� Cest etAt TA, U2.tt3Z Date Filed:AO "Ifyou would like e-mail\ notification of sign off please provide e-mail address: Owner Name: �. Q,(\ \c,\t\\\'leo Owner Address: \U\ Oryt7e5 Qs, OMe6\\'t p,&, non Owner Tel.No.:rjbQ)-7 MANI 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: P1 Ir DATE: 7/CAP/ PLEASE NOTE COMMENTS/CONDITIONS: 4 • RMOUJ MGL AND FIRE • . H TOWN OF YARMOUTH REVIEWED FOR CODE COMPLIANCE. �1�� ERRORS OR OMMISSIONS DO NOT RELIEVE THE APPLICANT FROM THE RESPONSIBILITY OF'AS BU TFCMPLIANCE. DATE: q't 6 i Ig U - 1\44G YARMOUTH FIRE PREVENTION PECTm.D 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 1; 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 1;20.6.2.5 *Trash Containers 527 CMR 1; 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 Ii.Smith, Date: 9/6/2018 Copy for Applicant I Copy to Building Department II Copy to Fire Prevention Entered in Firehouse n Final Inspection W 0 J / 96" / � ,, WW< • /a $ o V L 2 11� . 20a `g X12"-4r---- 31 2" / 22136" /13',6' / 16" / d ° 1 wit >- ayy O / 24" / 72" / z 9 0 mom y Qo ._12 U C m I- j W G t_cJ CT ,`j d' so. IMP M r Oo ..'-- 03 © N N ,;MBWTR ",. -I o \ OIL.WELLWORTH y in ft- p CO • StP 0 6 2018 E r a HEALTH DEPT. 1 \ N. N. N. \ 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 ^O^O applicable fee has been paid or job conditions. 1 1 order placed. 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