HomeMy WebLinkAboutBLD-19-1498 #3 • .• of•Y.1R BUILDING PERMIT APPLICATION
_ ; •
' . APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF,
' t � C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
4%' A Ot. wr K-«, S
Town orYitrmouth Building Department
��.+.,•� 1146 Route 28 . Yarmouth. MA 02564-1492
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 _
Perg� 7T� Office Use Onyn�(, Planning Board Information Assessors Department Information
ft'R6. -19-0 6 pate Plan Type Map Lot
Permit Fee $ Endorsement Date 3.?„ /1//
Recording Date New
Deposit Rec'd. $ 4 60Date Plan No. 1.4 Property Dimensions:
Net Due $ `"7777 Other Lot Area(st) Frontage(It) Lot Coverage
This Section for Office Use Only
Building Permit Number. ,r Date Issued: •
Signature: •✓.-4 c L q - /2 ../,F Certificate of Occupancy
Building Official Date is Is not required
Section 1 - Site Information
1.1 Propriety Address: P7 / 1.2 Zoning Information:
Zoning District Proposed Use
1.3 Building Setbacks(It) '
Front Yard Side Yards Rear Yard
Required 1 Provided Required Provided Required Provided
1.4 Water Supply(M.O.L e.40.3 54) 1.5 Flood Zone Information: Comments
Public Private Zone: BFE '
Section 2- Property Ownership/Authorized Agent
2.1 Owner /Record:
C(AaltS l : '
t) Mailing Address:
Signature 11UUU Telephone Telephone 7
Email Address:
2.2 Authorized Agent
Name(print) Mailing Address:
Signature Telephone Fax Email Address: I
Section 3-Construction Services
3.1 Licensed Construction Supervisor. Not Applicable ❑
c'-a\ '\Ytn4410A.
‘0 ,*i A (` „,\ _„\i`� kk� 0 Z (IV License Number
Address '11 l,'CYRZI 11 CS-tinh
— r _ 4 - 1 -44inuat Expiration Date
i tura elephona
Email Address: i\ViN`M
1 oto OVER__
• ,Section 6- Desgript!onaj Proposed Work(check all applicable)! -
' New Construction ❑ (tor multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms
- g Bldg.Existin 9 ❑ Repair(s) ❑ Alterations ❑ Addition ❑
94 1
Accessory Bldg. ❑ Type Demolition Other Specify:
. p fly:
Brief Description of Proposed Work:
f rn,q t PAr r t t,, ti A• . ('T 'uiP 0/A ttC-7S ,`A'(\P,L)at\brlut4
Ptn� 'llM IPtl 7. IDT —Ill 4M\\�3 n-"�. �
1 \\ w\ ({y '0 c?'Vhi kA kr filxv to LA' M:5e
Section 7- Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
• A ASSEMBLY l] A-1 ❑ A-2 ❑ A-3 ❑ IA 0
Al ❑ A-S ❑ 13 ❑
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ 23 0
F FACTORY ❑ F-1 0 F-2 ❑ 2C 0
H HIGH HAZARD 0 3A ❑
I INSTITUTIONAL ❑ I.1 ❑ 1.2 0 1-3 0 39 0
M MERCHANTTLE 0 4 ❑
R RESIDENTIAL ❑ R-1 ❑ R-2 0 R-3 ❑ SA ❑
S STORAGE 0 S7 ❑ 5-2 ❑ se ❑
U UTILITY I] SPECIFY: .
M MIXED USE 0
SPECIFY:
S SPECIAL USE 0 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(f applicable) Proposed
Number of floors or stories
Include basement levels
Floor Area per Floor(sr)
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 10a OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .
I, --1—rt C c ;4\c c)r.--' tA Xl ,as Owner of the subject property,
hereby authorize act on
myb l matters r I ' to work authorized by this building permit a plicatio .
Signature of Owner Date
3 of 4 OVER
•
i. -. • .
SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION
\L)-h ' \41‘t $V-2(M ,as Owner/Authorized Agent ' •
• A.
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.
S'WA N>st4Q, XY\
Print Name
vI3)))
Signature of Owner/Agent Date
Section 11 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
2.Electrical 5613
3.Plumbing/Gas
4.Mechanical(MVAC)
S.Fire Protection
S.Total.(1+2+3+4+5)
7.Total Square Ft tie nee ammo=s.Sthoial
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable) •
• r+•
•
4 of
•
j� • The Commonwealth of Massachusetts
L' . PI •=It Department of Industrial Accidents
. = Iii=. Office of Investigations
_ __�.r:111= .600 Washington Street
•
_ i
• = Boston,MA 02111
.' •www.mass.govidia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organintion/Individnal): V 1 \\ \�,ay 4)(Cat\
Address: 2() %tR fl
City/State/Zi.: w._ ; ; t., O Phone#: : — g t —ca 0
Are you an employer?Check the appropriate box:
1.0 I am a employer with 4. 0 I am a general contractor and I Type of project(required):
jemPloyees (fall and/or part-time).* have hired the sub contractors . 6. ❑New construction
2. 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• ❑Building addition
required:] 5. 0 We area corporation and its 10.0 Electrical repass or additions
3.0 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 iepairs
insurance'required.)t c. 152, §I(4),and we have no
3a.❑ I am a homeowner acting as a employees.[No workers't 13.0 Other -
general contractor(refer to#4) comp.insurance ]. -
"Any applicant that checks box#1 must also fill out the section below showing their workers' tion"
t Homeowner who submit this affidavit indicating they are doing all wort and then hire outsideo � Poems ibmit t asnew
iea.
g such.
t o tractors check this box must attached an sviditinn.l sheet showing the name of the sub-contractors and scamust m tether or noott those entidavit ties
employees. If the sob-contractors have employees,they most 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:
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 infatuation provided abovevis true and correct
•
Signatnre;� 091/0Date: �v .
Phone#: TI)�01-240 -(.d/4fl
•
IOfficial 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#:
T . -"4 'I:OWN-OF=YA1ZMOUTH-
o4 — — BUILDING DEPARTMENT — —
� y 1146 Route 28,South Yarmouth,MA 02664
- \" . .3'ily 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,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at-1\\ Qp'c\c2Q) Ai`(Yq(111r@lin. MA04
Work Address
Is to be disposed of at the following location: Cc) tM(u lr\'1(y1 CO.
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
9/300
Signature of Application Date
Permit No.
otgR TOWN OF YARMOUTH
° HEALTH DEPARTMENT
0 4 'f S
�•% PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: In RUM_ 2b S.\\Gmuvc ,t 1u'
k. OZ194y Pi-er
Propose Improvement: C4�.. ; N
‘,104.1 WO*, ani ``.n J
Applicant:%, �� �K,t}-''\ Tel.No.: 30%-206 -6220
Address: \ot0sk %9 (t'ASe 2422.— Date
"If you would like e-mail\ notification of sign off please provide e-mail address:
Owner Name: %.a�;Q(\ k'Y\c\\1X\jn ,�, \ �n
Owner Address: '0\ yjr c Ps\ v71C'(���C ��� 07.01,5 Owner Tel. No.:Set"2 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: 6M-11"// DATE: //CAP/
PLEASE NOTE
COMMENTS/CONDITIONS:
MGL AND FIRE
4404 TOWN OF YARMOUTH
REVIEWED FOR CODE COMPLIANCE.
• ' 4®� ; ERRORS OR OMMISSIONS DO NOT RELIEVE
THE APPLICANT FROM THE RESPONSIBILITY
��OF'AS BU 1' OMPLIANCE.
DATE:, �![+L
YARMOUTHI PECTO
FIRE PREVENTION
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 I ;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 I48;,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 1; 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 Cl.Smith Date: 9/6/2018
Copy for Applicant CI Copy to Building Department II Copy to Fire Prevention
Entered in Firehouse n Final Inspection
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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. L 1 order placed.
• PEIR 7 CONDO BATHS All Drawing#: 1 No Scale.
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