HomeMy WebLinkAboutBLD-19-1565 #20 . . of•v..tk BUILDING PERMIT APPLICATION
gf ; S APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF,
1 — . C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
E. ,..-J ; 4.. Town of Yarmouth Building Department
--.,••��ca' 1146 Route 28 • Yarmouth, MA 025544492
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836
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Office Use Only Planning Board Information Assessors Department Information
� - 'ceM/
Per �No. e
Plan Type Map Lot
Permit Fee $ Endorsement Date /
Recording Date New
Deposit Rec'd. $ Date_ Plan No. 1.4 Property Dimensions:
Net Due $ Other Lot Area(sf) Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit NNuu—mber.//� Date Issued: •
Signature: '/-G r,L 9J .) , -/& Certificate of Occupancy
Building Official Date is Is not . required
Section 1 - Site Information
1.1 Property Address: 1.2 Zoning Information:
%&e g\\00%4 NVik S(.0.04 2b
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(M.O.L c.40.S 54) 1.5 Flood Zone Informed= Comments
Public Private Zone: BFE
Section 2- Property Ownership/Authorized Agent
2.1 Owner of Record:
U A\IS Oti;\e 101L
pmtq / Mailing Address:
Signature Telephone Telephone Email Address:
2.2 Authorized Agent
Vt
ocr\A\\.pri\ev D'\ Q'� ' .c\ _ecig �?„tib,o 0,, y
Name(print) Mailing Address:
Signature Telephone Fax „WE�n-rail Addre5 I
Section 3-Construction Services
3.1 Licensed Construction Supervisor: Not Applicable
%W\1/4\ \ \\tt4(rI \
License Number
‘0‘a\).\\M
icenseNumber‘0Lall.\\\ CZACKa,h‘k. 0Z (4-1,7Address Sl:FMiS
_ i - — ,. -.Amuck
„ , - Expiration Date
1 tura elephone Email Address: "PAM
1ot4
,,on.0 Proposed Work(check all applicable)]
_,t ❑ (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms
..og. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
,asessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:( ^I . q �'1M) 'f'yrn)p c_ k rc U i , (ttz`ice_ c(tA 1 'Az ,nt111\(y1K4
Section 7- Use Group and Construction Type
Building Use Group(Check as appfcapable) Construction Type
• A ASSEMBLY ❑ A.1 ❑ A-2 ❑ A-3 ❑ IA ❑
A-4 ❑ A-5 ❑ 151 ❑
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ 2B ❑
F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL ❑ I-I ❑ 1.2 ❑ 1.3 ❑ 3B ❑
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑S STORAGE ❑ S-1 ❑ S-2 ❑ 53 ❑
U UrIUTY ❑ SPECIFY: • .
M MIXED USE ❑ SPECIFY:
S SPECIAL USE ❑ 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 7B0 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(s0
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 ONTRACTOR APPLIES FOR BUILDING PERMIT .
I, �rI ��c -L1 nS. ( __. • k4 4f1 , as Owner of the subject property,
hereby authorize \ to act on •
my behalf, in all matters I to work authorized by this building permit a plicatio .
Signature of Owner Date
•
•
3 of 4 OVER
,
SECTION lab OWNER/ER/AUTHORIZED AGENT DECLARATION
%n \
LAN t Ftctt',tc a/N , 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
*))133
Signature of Owner/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
2.Electrical \v
3.Plumbing/Gas •
V
4.Mechanical(HVAC)
5.Fire Protection
6.7=1.0+2+3+4+5)
7.Total Square FL Mi.s axvn a aenmq
Check Below
❑ Conservation-CommissIon Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable) •
o.;
sofa
' • . Section 6- Desgricrtorizti 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) 9 Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
At r
(I lye\ •h?:m,f JPYY. r v1 �,ti �ig P c`tx ,*IQ_ CALariff4
P\ cktAticti5 - ceIMAtq\ kiN '(Lyre t()artl '
ii
Section 7- Use Group and Construction Type
Building Use Group(Check as appricapable) Construction Type
_
• A ASSEMBLY 9 A-1 9 A-2 9 A-3 ❑ 1A LI
A-4 ❑ A-5 ❑ 1B 9
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ 23 ❑
F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD ❑ y1 ❑
I INSTITUTIONAL ❑ I.1 0 1-2 ❑ 1-3 ❑ 3B ❑
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA 13
S STORAGE ❑ S-1 ❑ 5-2 ❑ 5B ❑ .
U UTILITY ❑ .
SPECIFY:
M MIXED USE ❑
SPECIFY:
S SPECIAL USE ❑ 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 I •
Building Area Existing(if 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)
it
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—Ci Ca c -L,aC c c--- • t`-%Xt. ,as Owner of the subject property,
hereby authorize \\ to act on
my behalf, all matters rto work authorized by this building permit a pliCatio .
_)\ - . S� ZS�I t
Signature of Owner Date
•
3 of 4 OVER
•
A , . The Commonwealth of Massachusetts
� �_ Department oflndustrialAccidents
=_ =:t Office of Investigations
--1C-415— .600 Washington Street .
` Boston,MA 02111
'i..,-- •www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legibly
Name (BiuinessiorganizationRadividnal): V 6\ \\446.
tiN
Address: 90 Usk y,7
City/State/Zi.: %h\ ', - O'+ Phone #: ` — €I —(a; C
Are you an employer?Check the appropriate box:
1.0 I am a employer with 4. Q 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.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.insurance.: 9. ❑Building addition
required:] 5. Q We are a corporation and its 10.0 Electrical repairs 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
sTMa ce"retprired]t c. I So12.0 Roof repairs
3a.0 I am a homeowner actingas a , e 1s.[,and
general contractor(refer to#4) �1 workers'have no 13.0 Other
•
comp.insurance woor required.].
*Any applicant that checks box#1 must also fill out the section below showing thea workers'compeasatiodiaoliey infonaafion.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indican
g such.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employers. If the sub-contactors have employees,they must 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.Lie,if: . Expiration Date:
Job Site Address: City/State/Tlp: '
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Faure 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 pain and penalties ofperjury that the information provided abovevl� is true and correct
Sie;� •
gnaturDate: Jl��lrJ
Phone#: ' A-7(lb -Cd lin •
• 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 it:
�� -- !\O--"; -'c------ Lvy1Y1-vl'- 1-1-k Yv1V trti1-- ----- -----._ .
BUILDING DEPARTMENT
? ay °¢ 1146 Route 28,South Yarmouth,MA 02664
��j\�. 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,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 1\\ tckt\e?Q ���(i(V�1l1lt NI�. OZG(914
Work Address
Is to be disposed of at the following location: C-;€7.-., Q.I1 ) (V1 (0.
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
A13/)/0
Signature of Application Date
Permit No.
' ' gtgR TOWN OF YARMOUTH
ZAE •+'s-'ti
o y.,�J HEALTH DEPARTMENT
)•
x PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: lit Rot& 2? 5.\\Gtt s&% 3t%k. 021,(1L\ Qkr 1
ProposeVmprovement: is \► (C, t.. was
Applicant:%\i.\1/46 r,J \ A tiY\ Tel.No.: TjGe-Z 96 --(021.0Address: I‘o�p'{� �`� (..Vc\ X\ \\\t % U 24,%2.- Date
a � 1
'•Ifyou would like e-mail- notification of sign off,please provide e-mail address:
Owner Name: �eC t\ rp
Owner Address: tie` 0)0\66 76 XUN,_ 14, ( ?„0,;j Owner Tel.No.:S69)-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: t\-/-i DATE: 7/(//8
PLEASE NOTE
COMMENTS/CONDITIONS:
•
MGL AND FIRE
• ,0140877/ TOWN OF YARMOUTH
REVIEWED FOR CODE COMPLIANCE.
•
• wdt ERRORS OR OMMISSIONS DO NOT RELIEVE
THE APPLICANT FROM THE RESPONSIBILITY
OF'AS BUOMPLIANCE.
T'
DATE; P�G�IA¢.
YARMOUTHvl 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 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 Scan a.Smith. Date: 9/6/2018 .
Copy for Applicant 0 Copy to Building Department Copy to Fire Prevention
Entered in Firehouse 0 Final Inspection
M ISI 5
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All dimensions size designations This is an original design and must r 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.
•
I PEIR 7 CONDO BATHS All Drawing 14: 1 No Scale.
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