HomeMy WebLinkAboutBLD-19-1531 #14 . f rdR • BUILDING PERMIT APPLICATION
• soc ; $ APPLICATION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE,OCCUPANCY OF,
I ; + • C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
F .r."I�.., S Town ofYarmouth Building Department
•
�-+ ,.• 1146 Route 28 • Yarmouth, MA 02664-14512
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 _
Office Use Only Planning Board Information Assessors Department Information:
Perm it/OA/a_je_ Plan Type Map Lot
Permit Fee $ Endorsement Date tZ///j
—) Recording Date New
Deposit Recd. $(,Sol/ Date_ Plan No. 1.4 Property Dimensions:
Net Due $ Other Lot Area(sf) Frontage(h) Lot Coverage
This Section for Office Use Only
Building Permit Number. Date Issued:
S/,-a8 Certificate of Occupancy
Signature: � �
Building Official Date is is not required
Section 1 - Site Information
1.1 Property Address: 1.2 Zoning Information:
t',aNZ:I ) S`lurc`nwtl Za0r,4\ t4 .
Zoning District Proposed Use
1.3 Building Setbacks(ft) '
Front Yard Side Yards Rear Yard
IRequired Provided Required Provided Required Provided
1.4 water Supply(MALL c.40.S 54) 1.5 Flood Zone Information: Comments;
Public Private Zone: BFE
Section 2- Property Ownership/Authorized Agent •
2.1 Owner of Record:
0. a 0‘i:It
q Mailing Address:
CIS—t1S-047<
Signature Telephone Telephone Email Address:
2.2 Authorized Agent:
911 \1)\\\\14.PX(t ?P)%;)\ri i ?'rh.k Ali ), u
Name(print) Mailing Address:
' 10)
Signature Telephone Fax Email Address: I
Section 3 -Construction Services
3.1 Licensed Construction Supervisor Not Applicable ID
ccue1\\ \ (L,pc
€ License Number
\ ({5m`04c1,uk. oz u7
AddressCS SIS
5120_2 Q —(a Ito •110)1 t 0 aiiii Expiration Date
1 n tura Telephone V
Email Address: t\VAAVt)
rota
,-^on.d Proposed Work(check all applicable)]
9 (tor multiple family only) No.of Bedrooms (for multiple family only) No,of Bathrooms
„Lig. 9 Repair(s) ❑ Alterations ❑ Addition ❑
• .aessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
J 7r(l TmdP /Zk Q( hS gC-17 , & Ly.Alh y
4
1nA
«.ell'({5 -st0 c?,U cvA1r t`(\ came �ilAfxv;v
Section 7- Use Group and Construction Type
Building Use Group (Check as applicapable) Construction Type
• A ASSEMBLY ❑ A-I ❑ A-2 9 A-3 9 IA 9
A-4 9 A-5 9 131 9
3 BUSINESS ❑ a ❑
E EDUCATIONAL 9 23 ❑
F FACTORY ❑ F•1 9 F-2 ❑ 2C ❑
H HIGH HAZARD 9 3A ❑
I INSTITUTIONAL ❑ Ft ❑ 1-2 9 1-3 9 38 ❑
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL 9 R-I 9 R-2 ❑ R-3 ❑ SA ❑
S STORAGE ❑ S-I 9 S-2 9 58 ❑
U UNITY ❑ •
SPECIFY:
M MIXED USE ❑ SPECIFY:
S SPECIAL USE 9 SPECIFY:
Complete this section if existing building undergoingrenovations: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 a Building Height and Area •
• • Building Area Existing(if applicable) Proposed
Number of noors or stories
•
include basement levels
Floor Area par Floor(st)
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.-7r% (LI. \ -,"t\c er,-. • ti , as Owner of the subject property,
hereby authorize to act on •
• my
behalf, in all matters lar to work authorized by this building permit a plicatio .
Signature of Owner Date
3 of OVER
a y The Commonwealth ofMassachusetts
t•_r__= Department of Industrial Accidents
-- Office of Investigations
- . __ _ 600 Washington Street .
.. .r_ Y
Boston,MA 02111
.www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/PIumbers
Applicant Information Please Print Legibly
Name (Business/Organinidonandividnal): V ,\\ c.fltapic,NtA
Address: 90 tF,,, %1
City/State/Zi.: y., 0 Phone#: — if —(a p
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4. 0 I am a general contactor and I Type of project(required):
/employees(fall and/or part-time).: have hired the sub-contractots . 6. ElNew 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-contractors have g, 0 Demolition
wog 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.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their . 1 I. n
❑Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12.0Roof .
insurance required.)t c. 152, §1(4), and we have norepairs
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'compensatiodisolicy infonnabaa.
•
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such.
LContractors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have
—_--- erns have employees,they must provide their workers'commp,policy
ttum®bee
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.Lie.#
Expiration Date:
Job Site Address: City/State/Ttp:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Fenn to secure coverage as required tinder 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the paini and penalties of perjuzy that the information provided above is true and correct
Signattnr:� J�j%g
Date: i 2
Phone if: -CIA'L40 --Call-j[)
Official use only. Do not write in this area, to be completed by city or town official
City or Town: . Permit/License#
Issuing Authority(circle one): •
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
i-Vy7Y1-V1'-1Y11\Yv1VGLIl----._____..________.__
470:—
\� - BUILDING DEPARTMENT
' o 'i ''."\�y 1146 Route 28,South Yarmouth,MA 02664
.3'� 508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40,Section 54 and 780 CMR,Chapter 1, Section 111.5,
[hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 1,\ Q& %Q cAitito1ev1i+. 17z_f (4
Work Address
Is to be disposed of at the following location: 0.7:: (nU 11\'1p1 co.
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
9)/3NSignature of Application Date
Permit No.
ot ky TOWN OF YARMOUTH
o y. y HEALTH DEPARTMENT
• '' ••••`��$•
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: lit (Zou.\ 2?) S,.\\UcYnt91/441\�VOL o2. 41\ Vier '
Proposed Improvement: t,Gkk 'Cc
Vjesai calk DNA Skit°
Applicant:(►, �\\�3 %4 U Tel.No.: 5D? -Z96 -G2/1O
Address: \o �`� ( ccct' b\ _ WA, O 2-4-22.- Date Filed: eiN i
•'Ifyou would like e-mail notification of sign off,please provide e-mail address:
Owner Name: \ Vc,�-eS.VI0 ,�� \\ \n
Owner Address: �O\ FV 7� 1W. vc-AtVi � $. 07.6L5 Owner Tel.No.:5 -60)-2 D-411
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: a-^`l-- DATE: I/C//8
PLEASE NOTE
COMMENTS/CONDITIONS:
MGL AND FIRE
.00114, TOWN OF YARMOUTH
• D FOR CODE COMPLIANCE.
" RRORSEOR OMMISSIONS DO NOT RELIEVE
THE APPLICANT FROM THE RESPONSIBILITY
` ,'" OF'AS BUT FOMPLIANCE.
\./ DATE: r' 6/IQ .11
YARMOUTH FIRE PREVENTION 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; 182.4.1
x Building Numbers MGL Chapter 148;sec 59
x *Flammable gas/liquid storage 527 CMR l;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 I; 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 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 CL Smith Date: 9/6/2018
Copy for Applicant C Copy to Building Department II Copy to Fire Prevention
Entered in Firehouse I—I 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 job2O^O applicable fee has been paid or job
. ' conditions. 1 order placed.
•
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