HomeMy WebLinkAboutBLD-19-1423 / 0/jir
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of•YgR BUILDING PERMIT APPLICATION
• 't
. .a.:.$.a.:.$ + APPUCATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF,
• i C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
ka :::���-(� .-3 Town ofMinnouth Building Department
V;::::"•�^ q 6 t 2
1146 Route 28 • Yarmouth, MG1(1_bb-1—F-1.1
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836
—
Office Use Only�� Planning Board Information Assessors Department Information:
IA)—
Perms No. �� 77 ate_ Plan Type Mee w
Permit Fee /eV' CO Endorsement Date 031/ /33•
// ordnq Date New •
Deposit Recd. $ .b760ate I9ec ecNo 1.4 Property Dimensions:
Net Due $ 5G,j— Other Lot Area(sf) Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number. Date Issued
�,�/G� 9—/O/� Certificate of Occupancy
Signature:
unding Offi ' Date is Is not required
Section 1 - Site Information
1.1 Property Address: 1.2 Zoning Information:
t ,51// /ef 2-a wyfizryoJT 1/4 .
0 2477
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 Information: Comments '
Public Private Zone: BFE •
Section 2- Property Ownership/Authorized Agent •
2.1 Owner of Record; /
3 /1/C1/tL /t/ 4L C.-^ O•
WName(prin � -" A Gtl.., I et• QuSC 21 2iF f'/'`1lTR'�S
Mailing Address: Ce„ys -
rose7? tole( .�1'77e Z/ ye( .rr, a/o .,../
Signature ' . —
Telephone Telephone Email Address:
2.2 Authorized Agent
///e,1/4j/friihnG-- • ? to. 6,29\ ? fzy .
Name(print Mailing Address: Co",en rT
i 7�L 'L/ yznmyi73. „n`
sign uFe Telephone Fax Email Address: I
Section 3-Construction Services :_ E ; V e t)
3.1 Licensed Construction Supervisor No Applicable U
7)/941), 11,40c,.D_j. V , , 218
3 `' /d'o v✓ i'
/1 � /"/[ I-
P
G eI�"/ Number
l/ ce%"/.47t-t :,,c,;---25 if/9 72° Expiration Date
Signature -Telephone Email Address:
.
3.2 Registered Home Improvement Contractor. •
Company Name Not Applicable ❑ -
'.. Registration Number
Address
Expiration Date
Signature Telephone
Section 4•Workers'Compensation Insurance Affidavit(M.G.L C. 152 S 25C(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No
Section 5- Professional Design and Construction Services-for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect
• Not Applicable ❑
Hams (Registrant): Registration Number
Address
Expiration Data
Signature Telephone
Section 5.2 Registered Professional Engineer(s)
Name Area of Responsibility
Address Registration Number
Signature Telephone E piretion Date
Area at Responsibility
Name
Address Registration Number
' Signature Telephone Expiration Date
Name
Arae of Responsibility
Address Registration Number
Signature Telephone Expiration Date
•
Hams Area or Responsibility
Address• Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor
Not Applicable U
Company Name
Person Responsible for Construction ,
Address
Signature Telephone
"a
I
• . Section 6- Description of Proposed Work(check all applicable)
•
New Construction ❑ (tor multiple family only) No.of Bedrooms (tor multiple family only) No.of Bathrooms
Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
Q rAf- y
jga
•
Section 7- Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
• A ASSEMBLY ❑ A-i ❑ A-2 ❑ A-3 ❑ to ❑
_ A-4 ❑ A-S ❑ 130
B BUSINESS ❑ • 2A ❑
E EDUCATIONAL ❑ 213 0
F FACTORY ❑ F-I 0 _ F-2 0 2C 0
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ as 0
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL 0 R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S STORAGE ❑ s-1 0 5-2 0 5e ❑
U UTILITY ❑ SPECIFY: •
M MIXED USE ❑ SPECIFY:
S SPECIAL USE I] 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 •
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)
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 •
r6 fl v ,as Owner of the subject property,
hereby authorize _!v )160-041,r to act on
ri' ���
my behalf, in all ma relative to ork horizedby this building permit application.
/3i 7
Slgnatu of saner Date
i
e
SECTION 1Ob OWNER/AUTHORIZED AGENT DECLARATION
I, , 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
Signature of Owner/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
hem ' Estimated Cost(Dollars)to be
completed by permit applicant
I.Building
Electrical
•
3.Plumbing I Gas
4.Mechanical(HVAC)
S.Fre Protection
6.Total.(1+2+3+4+5) ?,Q[}(f
7.Total Square Ft P.r.w mcvw i✓ .1
Check Below
Cl Conservation-Commission Filing
(if applicable)
Cl Old Kings Highway&Historical •
Commission approval
(if applicable)
•
• The Commonwealth of Massachusetts
'
_•_ Department of Industrial Accidents
t
' • =_= '•=`- Office of Investigations
i— 'c‘. .600 Washington Street •
Boston,MA 02111
smog.
•www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individuat): ''' .,1;2-c//2 #2J oe,iDS
Address: +Cr /J�i¢Tli ,te-t--.e.c.., snis..9 + •
City/State/Zi : fjaj v, i �i A er Phone#: Sam `�/f 77trC
Are yon 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):
egiployees(fall and/or part-time).: 7have hired the sub contractors . 6 ❑N construction
2. I am a sole proprietor or partner- listed on the attached sheet . Q 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, insuranceComp.insurance.:
9. 0 Building addition
required:] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions _
3.❑ I am a homeowner doing all work officers have exercised their . 11.0Plumbing
right exemptionper MGL or additions
myself [No workers' comp. rit of .
in� ance required.)t c. 152, §1(4),and we have no 12.0 Roof repairs
3a.❑ insuranceI am a homeowner acting as a employees.[No workers' 13.❑Other •
general contractor(refer to#4) comp.insurance required,]:
May applicant that checks box#1 must also fill out the section below showing their workers'oompensatio4olicy information.
t Homeowner 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.eonbsctoa and state whether or not those entities have
employees. If the sub-contractors ban 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.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.
JI do hereby cer�doer the fain an enalttiiees of perjury that the information provided above is true and corre
Sicaturr --)22't-}"Ce -
� �s� / dv?/6�✓ 0.-2/ / IDate: 0 •
Phone#:
•
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.BuIIding Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions "•
=f
Massaclnuctt General Laws chapter 152 requuss.all employ&,to provide workers'.compeasation for their employees.
Ptasuarn to this statute,an employes
is defined as"_every person in the service of another under any contract of bite,
express or implied,oral or written."
is defined as"an individual,partemploaarhip,association,corporation or other legal entity,or any two or more
o f aforeyrgning engaged lin a joint eotergiu.and including the legal representatives of a deceased employes,or the
of the fore
receiver or tastes of an iadivthal,psztaship,association or other legal entity,employing employees. However the
owner of a dwelling!muse having not mite than three matter=eats and who resides therein,or the occupant of the
dwelling house of another who employs persons to do rniint: •"re,construction or r work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such=playact be deemed to be an employee
MOL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct haifdily la the eetamoawealth for ay
applicant wise has net produced acceptable evidence of compliance with the lasmsaes average required."
• Arwi*.v.11y,MGL chapter 152, §25C(7)states"Neither the commonwealth nit say of in political subdivisions shall •
enter into any contract far.the of public work until acceptable evidence of=pith=with the=inn=
requfrementa of this chap=hove been presented to the contacting authority."
•
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(,),address(es)and phone number(,)along with their certificate(s)of
instasnca Limited L absiity Cmnpame(LLC)or Limited Liability Parmaships(112)with no employees other than the
neuters or partners,are not required to carry workers'compensation inanimate. If an LLC or LLP does have
-employees,a policy is required- Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insane=coverage. Abe be sore to sip sad date the affidavit. The affidavit should
be=turned to the city or town that the appiicatioa for the permit or license is being requested,not the Departm et of
Industrial Accidents. Should you have any questions regarding the law or if you are reed to obtain a workea'
compensation policy,please call the Department at the number listed below. Self-inured companies should enter their
self-insurance license amber on the appropriate liar-
City or Town O(IIdais
Please be use that the affidavit is complete and printed legibly. The Department has provided i space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations ha to contact you regarding the applicant
Please be sure to fill in the permit/license ntnnba which will be used a a reference mamba. In additive,an applicant
that nmst submit multiple pamitllicense applications in any given year,need only submit one affidavit indicating cants
policy infant=(if necessary)and under"lob Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped cc marked by the city or town may be provided to the
applicant se proof that a valid affidavit is on file for future permits or licenses. A new affidavit aunt be filled out each
--_—__year.Where a bone owner or citizen is obtaining a license or permit not related to any business or commacW venture
(i.e.a dog license or permit to bran leaes etc.)said person is NOT requited to couplets this affidavit.
The Office of Investigations would like to thank you in advance fur your=operation and should you have any questions, —
please do not hesitate to give us a call
the Departments address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oaks of Investigations
• 600 Washington Street
Boston,MA 02111
Tel. !1617-727-4900 ext 406 or 1-877-MASSAFE. .
Fax 1 617-727-7749
Revised 11-22-06 www.mass.gov/dia
set
'Y ,„ TOWN OF YARMOUTH
:. e 0 BUILDING DEPARTMENT
-st '£ 1146 Route 28,South Yarmouth,MA 02664
O `C y
p"
. cs3"'T�..�..3�a$ 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,
1 hereby certify that the debris resulting from the proposed work/demolition to be
conducted at $y/ (RIP a V
Work Address
Is to be disposed of at the following location: c.2)0m6-7-02- 4
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Sign. of Application I ate
t; ISO EC-7
(—
Permit No.
•
Commonwealth of Massachusetts
®� Division of Professional Licensure
Board of Building Regulations and Standards
Co nstrradrf'$dpervisor
CS-035693 •. Wires: 01/18/2020
i 5
DAVID A.WOODS •-?
43 MATTNEWWAY
MARSTONS MILLS MA 02648
'rixrl lJ \ • ' moi
Commissioner
1
MGL AND FIRE
REVIEWEODVFOR CODE COMPMAOUTH
N� ) l ERRORS OR OMISSIONS DO NOT RELIEVE
/ THE APPLICANT FROM THE RESPO
OF'AS BUI CO Pl1ANC NSIBILITY
!b DATE: W 8-
I TOR
YARMOUTH FIRE PREVENTION
Commercial Construction Building Transmittal
Project Name: The Yarmouth Smoke Shop Address: 541 Route 28
Contact Name: Ali Jameel Phone: 508-446-4433
Y NO NA Subject Regulation
E
S
x Access for Fire Apparatus 527 CMR I; 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 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
x Sprinkler Systems* 780 CMR&Chapter 148 sec 26 A-I
x Storage inside/outside Buildings 527 CMR l; 10.19.4,4.4.3.1.1,19.1.2,34.1.1
x *Upholstery 527 CMR 1;20.6.2.5
x *Trash Containers 527 CMR 1; 19.1.1, 1.12
x Any Hazard to the Public Chapter 148;sec 28
x *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:
Upgrade sprinkler system to meet code and have sprinkler company sign off when
complete.
Fix Emergency lighting
Replace Fire Extinguisher near rear exit door.
Plan Reviewed By: Captain/Inspector Capt.Nevin.9fucP Date: 08/31/2018
Copy for Applicant 0 Copy to Building Department II Copy to Fire Prevention
Entered in Firehouse fli Final Inspection
.tne<itts EggEin CD TOWN OF YARMOUTH gagyFig
• o ;,A _ 04 2018 HEALTH DEPARTMENT
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• 018
`10- HEA'PE 'D _ • = w'LICATION SIGN OFF TRANSMITTAL . 7:11LTH DEPT.
To be completed by Applicant: c� ,�yl�
Building Site Location: e5-7/ /Qo `�° o< Qp G✓GS% X5b01 a r1 m'#• q1 G 73
Proposed Improvement: /3Gllitc/i q cif4:70 nd /JL142,2)00R
Applicant: 4L' v/ in-- Tel.No.: si'-YV4 3
Address: 9„4 59wla.Pcf/ 4p-Al ,q-r se — do?3,?Date Filed: 9/3//fg
**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: /7/61/245 /V G c c •
Owner Address: /0, .7 • 2 121 71,1,4V/1 Owner Tel.No.:7 /, -t t y y
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. / J �y
REVIEWED BY: /�� 9 &t..o /f DATE: r/y // �5
PLEASE NOTE
COMMENTS/CONDITIONS:
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'4V44 OF YARMOUTH
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REVIEWED FOR BUILDING AND ZONING CODE COMPU.
ANCE. ERRORS OR OMMIRSIONS DO NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILITY OF "AS BUILT'
COMPLIANCE
•.:...:;::f *:
DATE: '/0 / ' s..l;;:- ,
077/"..BUILDING OFFI .
. FILE COPY
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