HomeMy WebLinkAboutBLD-19-1524 #12 0—y4k.. BUILDING PERMIT APPLICATION
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PLICATION TO CONSTRUCT, REPAIR.RENOVATE, CHANGE THE USE, OCCUPANCY OF,
Dr mEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Twn o 'amouth Building Departmen1146 Route 28 • Yarmouth, MA 02664-4492
Tel: 508-398-2231 ext. 1261 Fax 508.393-0836 _
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'}h� Otrce"es?ny Planning Board Information Assessors Department Information:
irt ,0�9� aldte Plan Type Map La
Permit Fee $ / Endorsement Date 32,/)//
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Recording Date New
Deposit Reed. $ � Ddte_ Plan No. 1.4 Property Dimensions:
Net Due $ y" Other Lot Area(sl) Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number. Date Issued:
Signature: • r_ /.ri q —/7-It Certificate of Occupancy
Building Official Data is b not required
Section 1 - Site Information
1.1 Property Address: ?f/ 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
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•
1.4 Water Supply(M.O.L c.40.5 54) 1.5 Flood Zone Information: Comment=
Public Private Zone: BFE •
Section 2- Property Ownership/Authorized Agent
2.1 Owner of Record:
t) / Mailing Address:
t- --' CCS—11S-61- 'J
Signature Telephone Telephone Email Address:
2.2 Authorized Agent
V ori WW\\wet\gcc,rA V \X1`1 i ? ?'C),1\,A 1, O, it2,1
Name(print) Mailing Address: ,',',`p`'(('�� �,,}�(��n�.
Sign Telephone Fax Email •Of di 1 i
Section 3-Construction Services
3.1 Licensed Construction Supervisor. Not Applicable i]
License Number
IkAV Y\ C c\ia\t? hk U 2 G37
,
Address LS-(6j 1SS
5/20-2 W.)-C, 41'Imui.(e Q'tho,2an, Expiration Date
i toreTelephone Email Address: tOu`Vb
' • . Section 6- Descrion.rl Proposed Work(check all 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. 0 Type Demolition Other Specify:
Brief Description of Proposed Work:
gfOrIr, Tftnf7P\c. UA-44—Sown (Z.K PtX-isc-PS: ' ,1�r.�Ll�i(rr(i
P \AO/S{5 - 1ce,YW (\ Loci 1�x
Section 7- Use Group and Construction Type
Building Use Group(Check as appricapable) Construction Type
•
• , A ASSEMBLY ❑ Al 0 A-2 0 A-3 ❑ IA 0 -
A-4 ❑ A-5 ❑ 113 0
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ 2H ❑
F FACTORY ❑ F-I ❑ F-2 ❑ 20 ❑
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL 0 - I.1 ❑ 1-2 ❑ 1-3 0 39 0
M MERCHANTILE ❑ 4 0
• R RESIDENTIAL 0 R-1 0 R-2 0 R-3 ❑ SA 0
S STORAGE ❑ S-1 0 5-2 0 5e 0
U UTILITY 0 SPECIFY '
M MIXED USE ❑ SPECIFY:
S SPECLAL USE 0 SPECIFY:
Complete this section if existing building undergoing renovations:additions and/or change tri 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(sq
Total Area All Floors(sf)
Total Height(ft) ,
Section 9-STRUCTURAL PEER REVIEW (780CMR 110 11) d
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. `i n (LN.-V-,..-ft r--- • t\ v. , as Owner of the subject property,
hereby authorize \ to act on
my behalf, l mattersto work authorized by this building permit a plicatio .
.. stiaii
Signature of Owner Date
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3 of 4 OVER
SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION
(
I, 104NY11.. \ tINA.tcw /\ ,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.
%)...a\\ %arekilDA
Print Name
003 ' '
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)
3.Plumbing/Gas
4.Mechanical(HVAC)
S.Fire Protection
6.Total.(1+2+3+4+S)
7.Total Square Ft.horn..mcan•t.SIt.t
Check Below
❑ Conservation-Commission Fling
(it applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable) •
•`'
4 oi4
% The Commonwealth of Massachusetts
• I; Department of Industrial Accidents
-• :=`t Office of Investigations
- • • _ �y= 600 Washington Street
t_ _:
Boston,MA 02111 •
•
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Blumessiorganirationgndividtw): (teari\\ \\, i `rA
Address: Qp Usk tin?
City/State/Zi.: ,�, , , p Phone#: ; — g, — (i1
Are you 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 (fall and/or part-time).* have hired the sub contractors . 6• ❑New coastuction
2.1M I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have g• 0 Demolition
working for me in any capacity. employees and have workers'
insurance Comp,insurance.:
[No workers'comp. 9. o Building addition
required:] 5. ❑ We are a corporation and its I0.❑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 Roof 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 ]• -
}Any applicant that checks box#1 must also 811 out the section below showing their workers'compcnsatiodponcy infoniion.
Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contactors est submit a new affidavit indicating suck
tConttaerms 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-contractors have employees,they most provide their workers'comp.policy numbet:
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-ms.Lie.#: - 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 certrfy under the pains and penalties of perjury that the information provided above is true and correct
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Sigaature: Date: t�9131/10
Phone#: 5A-2 0 —C 4('
Official use only. Do not write in this area, to be completed by city or towi oiciaL
City or Town: •
Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Budding Department 3.City/Town Clerk 4. Electrical Inspector 5.Numbing Inspector
6. Other
Contact Person: Phone#:
?: L---"\ _._t---- TOWN-Ole-YARMOUTH—•
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y BUILDING DEPARTMENT
tr. 1146 Route 28,South Yarmouth,MA 02664
508-398-2231 exL 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 1113,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at f1\1 Qakese7q) CAATIlllklll1. (7aivl{
Work Address
Is to be disposed of at the following location: 4-IS /r_u a iA'1p1 (P.
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
IP0
Signature of Application Date
Permit No.
=ot*Ygk,� TOWN OF YARMOUTH
• c HEALTH DEPARTMENT
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PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: �1
Building Site Location: in Rowe 2?) S.\\UIYyluw )N. 024411PI�r 1
Proposed Improvement: 1,0,k ft t.. r.
View c-ktitien c> Skno
Applicant:%,A6 t j %h O.C.-01\ Tel.No.: 5021-Z 96 'LAO
Address: \Apt WI (1,1AR, \)\\1t WIAL 02-lo7-Z. Date Filed: g__
"If you would like e-mail\ notification of sign off please provide e-mail address:
Owner Name: tAtt(\ V k\`vl\rn` ,� \ \n
Owner Address: �0\ 0)0\66 a. OcAt(��\�p4. 02_6(15 Owner Tel.No.:Si t�-?2O-1199
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: DATE: 7/C//A
PLEASE NOTE
COMMENTS/CONDITIONS:
RMOUj MGL AND FIRE
.1P b TOWN OF YARMOUTH
•
REVIEWED FOR CODE COMPLIANCE.
d ERRORS OR OMMISSIONS DO NOT RELIEVE
Q THE APPLICANT FROM THE RESPONSIBILITY
+EIrty ! OF'AS BU T OMPLIANCE.
\
j• DATE: 4'(61
YARMOUTH FIRE PREVENTION or
I PECTO
Commercial Construction Building Transmittal
Project Name: Pier 7 Address: 711 Route 28
Contact Name: Randall Henderson Phone: 508-280-6240
4.
Y NO NA Subject Regulation
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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;422.2.1
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 l;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 *LPC 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 I; 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 a.Smith. Date: 9/6/2018
Copy for Applicant I Copy to Building Department Copy to Fire Prevention
Entered in Firehouse C 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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