HomeMy WebLinkAboutBLD-19-1558 #15 of'rift BUILDING PERMIT APPLICATION
APPLICATION TO CONSTRUCT,REPAIR, RENOVATE , CHANGE THE USE,OCCUPANCY OF,
o '_ C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
• F \„,,,_�-, ; S. Town of Yarmouth Building Department
,_.,.e.g 1146 Route 28 • Yarmouth, MA 02654-1492
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836
—
` j Office Use On Planning Board Information Assessors Department Information:
Permif No�9-a 0:1 ZZ ate_ Flan Type Mev La
Permit Fee $ Endorsement Date ?/ /)9
Recording Date New
Deposit Recd. $ til Date_ PWn No. 1.4 Property Dimensions:
Net Due $ Other Lot Area(sf) Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number. Date Issued: •
Signature: '✓-4=
1--/, - /k Certificate of Occupancy
Building Official Date is _ is not required
Section 1 - Site Information
1.1 Property Address: 1.2 Zoning Information:
Vie* s‘\ a. 7u Rcx>r,\ lc •
Zoning District Proposed Use
1.3 Building Setbacks(N) '
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
• 1.4 Water Supply(M.O.L C.40.S 54) 1.5 Flood Zone Information: Comments
Public Private Zone: BFE '
Section 2- Property Ownership/Authorized Agent
2.1 Owner pt Record:
\Aa VS -v%
• t)
—^— ct--: --(res-6i7‹ Mailing Address:
Signature Telephone Telephone Email Address:
2.2 Authorized Agent
9 ocA.t \\\' ed( cr nr\ e") ` P +7A?'C0`4 vT ti 7.9
Name(print) Mailing Address:
Signattre Telephone Fax Email Address:
Section 3- Construction Services
3.1 Licensed Construction Supervisor Not Applicable ❑
ccie i\\ \\ t $Lp\
‘0 WA c.46 ,_v��, r`Z (fig License Number
Address 'lJ 'LNtI V (,S VV71�.7
ti/) -2iC)—(,QUO -Vim ur,(eu1Eiboo ar►1 Expiration Date
i tura Telephone Email Address: i\\?ikti)
4__.....___.._..-._ _._._ ___. 1of4
. Section 6- DesyriFon.4 Proposed Work(check alt 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. Q Type Demolition Other Specify:
• • BriefC;11'
Description of Proposed Work: •p
. ^`''f79rr) to:mf �P�rr. r Un ,. Am cZ4K P Q {A1,C6•Jei\Q LY-1\briatti
P\-\\ -ki-AU r5 —NO c &&\A kiN SAre 10CLA St
Section 7- Use Group and Construction Type
Budding Use Group (Check as applicapable) Construction Type
• A ASSEMBLY ❑ A-I ❑ A-2 ❑ A-3 CI 1A
A4 ❑ A-5 I] 113
'
B BUSINESS 1:1 2A Ci
E EDUCATIONAL ❑ 23 ❑
F FACTORY ❑ F-I ❑ F-2 O 2C ❑
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL 3 I-t ❑ 1.2 ❑ 1-3 ❑ 3B ❑
M MERCHANTILE ❑ 4 O
R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S STORAGE ❑ S-I ❑ S-2 ❑ sa ❑ .
U UTILITY ❑ SPECIFY: • .
M MIXED USE ❑
SPECIFY:
S SPECIAL USE 3 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(It 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)
It
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 1 Ca OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNER'S AGENT ORONTRACTOR APPLIES FOR BUILDING PERMIT .
I, �1.rr C: N. .11 C, e Q--- • tk t\ , as Owner of the subject property,
hereby authorize to act on
my behalf, l mattersI t' to work authorized by this building permit a plicatio .
x 'N - • €� 2 It
Signature of Owner Date
3 of OVER
fR
SECTION lob �OWNER/AUTHORIZED, ` AGENT DECLARATION
( \
I, .$s t W.hl1.Q(4(M , as Owner/Authorized Agent 1^y
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.
V v\\ . m •
Print Name
VI3))13
Signature of Owner/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item • Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
2.Electrical 6)
3.Plumbing/Gas IL}
66)
4.Mechanical(HVAC) •
5.Fire Protection
5.Total all a 2+3.4♦5)
T.Total Square Ft A.nee mums 4 Sacra)
Check Below
❑ Conservation-Commission Filing
(if applicable)
•
U Old Kings Highway&Historical
Commission approval
(if applicable) •
'h
40( 4
`� The Commonwealth of Massachusetts
�;=-.--. •
=,t Department of Industrial Accidents
K'.=`- Office of Investigations
•
• _' — " 600 Washington Street
—= Boston, MA 02111
•www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): t(04\\ �,11 )"tclA
•
Address: 90 tsok tbl
City/State/Zia: y,,: ,, 0' Phone#: . —(ca O
Are you an employer?Check the appropriate box:
4. Type of project(required):
I.❑ I am a employer with ❑ I am a general contractor and I
employees (fall and/or part-time).* have hired the sub-contractors . 6 ❑New construction
2.M 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.insurances i 9. ❑Building addition
required:] 5. 0 We are a corporation and its I0.0 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 Roof Spain
insurance required.]t c. 152, §1(4), and we have no
33.1_1 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 est also fill ma the section below showing their workers'compensatiot4olcy information-
t Homeowners who submit this affidavit indicating 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-contract®have employees,they mast provide their workers'comp.policy=ber.
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 cele wider the pains and penalties of perjury that the information provided above is true and correct
Si�attre;� Date: 0fie
Phone#: - •
(Lin
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#:
-1'U4VN-01eY-ARMOUTH-- — —
BUILDING DEPARTMENT
me
o •i"- ' '' 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 1, Section 1113,
[hereby certify that the debris resulting from the proposed work/demolition to be
conducted at \\ '2l&t P7Q SAi'(YqamVNit. O?LIA
Work Address
Is to be disposed of at the following location: CY'S trift ip1 (.0
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
/)/0
Signature of Application Date
Permit No.
ot_ZAk TOWN OF YARMOUTH
•• 3c HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 111 Rou&2 2b S.' Prat :_OLbv-\ Peer 7
Proposed Improvement: 14kt ft,
J
Applicant:.&kvk%�,� t114 i1
,UZV\ Tel.No.: See-296 -1,2Na
Address: VW. %h (f t' a\\`t hk, OZIp?aL Date Filed: iNit,
**Ifyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: Wit\ cY7\t_ 1np
Owner Address: ri0\ 76 R\. Or-Aa. y&, O2 L5 Owner Tel.No.:T,6?-?&_1411
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: PIP DATE: ! CA8
PLEASE NOTE
COMMENTS/CONDITIONS:
MUT MGL AND FIRE
4, H TOWN OF YARMOUTH
• REVIEWED FOR CODE COMPLIANCE.
ERRORS OR OMMISSIONS DO NOT RELIEVE
Qa�1�� THE APPLICANT FROM THE RESPONSIBILITY
i OF'AS BU T'COMPLIANCE.
DATE: Cit 1 11:1
YARMOUTH 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 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 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 O Copy to Building Department 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 jobO^O applicable fee has been paid or job
conditions. 2020 order placed.
' • PEIR 7 CONDO BATHS All Drawing#: 1 No Scale.
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