HomeMy WebLinkAboutBLD-19-002439 • ., :
.01 creAdiBUILDING PERMIT APPLICATION
2F • 'trAPPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF,
3 ; + C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Y ..._. $, Town of Yarmouth Building Department
�•+.•11•"g 1146 Route 28 • lannouth, MA 02664-1492
Tel: 508.398-2231 ext. 1261 Fax 508-398-0836
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SLAA—IQ D 'c�u Planning Board Information Assessors Department Information: •
-{�lJotl "/
Permit No. Date_ 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 Number. Date Issued: •
Signature::,..y Atri i# if Certificate of Occupancy
tali g Official // Data is ' Is ndt required
Section 1.- Site Information (/
1.1 Property Address: ' 1.2 Zoning Information:
aa; oxp6 r
yor-w-LI VYI- tea 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 Informedorc Comments:
Public Private Zone: BFE R E C El V E I)
Section 2- Property Ownership/Authorized Agent I Off242018
2.1 Owner of Record: 1
iPOO� �
Namtpa:440:2/....1 _. �R`•T7; ., T
Maling Address: nye '�ty�—isign�ureTelepn Telephone • Email Address:
2.2 Authorized Agent
Name(print) Mailing Address:
•
Signature Telephone Fax Email Address: i
Section 3 -Construction Services •
3.1 Licensed Construe ion Supers art Not Applicable ❑
-,r , ./G e
A. at
✓ 9. 3 v ✓1(viz- +S cin /'ey 5 way _6f, b tt(4c) License Number ,/
Address / , y 0 9 —2 yS
� 1, engq r�qq diV� tbrooEx�tionDate(
nature Telephone Email Address: 7/g 196
3.2 Registered Home Improvement Contractor.
Company Name Not Applicable ❑
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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 1
Not Applicable ❑
Name(Registrant): Registration Number
Address
Expiration Date
Signature Telephone
Section 5.2 Registered Professional Engineer(s)
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
PlaineArea of Responsibility
Address Registration Number • .
' Signature - Telephone Expiration Date
Name • Area of Responsibility
•
Address Registration Number
Signature Telephone • Expiration Date
Area of Responsibility
Hama
Address Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor
Not Applicable CICompany Name •
Person Responsible for Construction
Address
Signature Telephone - '
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Section 6- Description of Proposed Work(check all applicable)
_New Construction ❑ (tor multiple lamily only) No.of Bedrooms (for multiple family only) No.of Bathrooms
Existing Bldg. ❑ Repair(s) 0 Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
yea-`fG ^ INA 6 (cvIyn S , ycJQi4IJ
Section 7- Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
• A ASSEMBLY 0 Al ❑ A-2 ❑ A-3 C) 1A ❑
A-4 ❑ A-5 ❑ 1e ❑
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ 28 ❑
F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL ❑ 1-1 ❑ 1-2 ❑ I-S ❑ 38 C)
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL ❑. R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S STORAGE ❑ 5-1 ❑ 5-2 ❑ Se ❑
U UTILITY ❑ •
SPECIFY:
M MIXED USE ❑ SPECIFY:
5 SPECIAL USE ❑ SPECIFY:
Complete this section If ex-isting building undergoingrenovations;additions and/or change hi use.
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section B Building Height and Area •
Building Area Existing(if 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 1 0a OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/ I, Yb o b 5 , as Owner of the subject property,
hereby authorize to act on
-my behalf, in all matters relative to work authorized by this building permit application.
st
- re:2 3i 6
Signature of Owner Date
.a a .,..�..
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SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION '
I, , as Owner/Authorized Agent
Jhereby 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.
•Pnnt Name
Signature of Owner/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item • Estimated Cost(Dollars)to be
completed by permit applicant
1.Building 2
2 Electrical
3.Plumbing/Gas
4.Mechanical(HVAC)
5.Fire Protection
J6.Total.(1+2+3.4+5)
7.Total Square Ft serrwwinan&Wave)
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
, , The Commonwealth of Massachusetts
.
` =_ Department of Industrial Accidents
u/.=`t Office of Investigations
- � — "
.600 Washington Street •
•
--,` Boston,MA 02111
0.
•www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Or jintion/individnal): j OSitt.,t a, "6- .
1// Address: '7 3 unof`c 5 dktLeI 'S Li 0,1
City/State/Zip: O tj,f) _ Phone#: 360 8 qv ooO`V V
Are yon an employer?Check the appropriate box:
4. Type of project(required):
I.❑ I am a employer with ❑ I am a general contractor and I
have hired the sub-contractors . 6. 0 New construction
employees(full and/or part-time).*
2.R34 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. 0 Building addition
required:] 5. ❑ We are a corporation and its 10.0 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 MOL
12.0Roof 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 required.].
•
'Arty applicant that checks box#1 cont also fill out the section below showing their workers'compensatio$policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such.
:Contactors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I ant 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/Trp: '
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 cernfy under the paini d penal ' f perjury that the information provided Signature: -- a/bbovee is true and correct
6 Date: 7 340
Phone#: T
1 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#:
Information and Instructions
hap mom• employers promsro for their employees, •
Massachusetts General Laws chapter 152 allto workers' ' tion contact of hire,
Pursuant to this statute,an rapiycs is defined as"_.every paean in the service of another under arty
express or implied,oral or written."
An espfsywr it defined as"aa ioddividual,partnership,association,corporation or other legal entity,or any two or mom
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased empbyts,a the
receiver or trustee of an bdiridrnl,psrtaasbip,association of other legal entity,employing=Payees. However the
owner oft dwelling home having not more thin three apsrtreats and who resides therein,or the occupant of the
dwelling house of anther who employs persons to do rssinr.naer;construction or repair work on such dwelling house
or on the grounds or braiding appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter. 152, §25C(6)also states that"every state or local licensing tgeacy shall withhold the inane or
renewal of a license or permit to operate s business or to contract bdidlep la the eonmoeweslth for say
applicant who has not produced acceptable evidence of compliance with the Innate avenge regrind."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth ear any of its political subdivisions shall '
eater into any contact for the pert of public work until acceptable evidence of compliance with the i,.stanee
require:c ats of this chapter have been presented to the contacting authority."
Applicants
Please fill out the workers'compensation affidavit completety,by checking the boxes that apply to your*nation and,if
necessary,supply sub-conractogs)name(s),addtesa(es)and phone namba(s)along with their certificate(*)of
innate. Limited Liability Connie:(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or pacers,are not zequired to carry,workers'compensation Monne. If an LLC oc LLP does have
aaployees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
' Accidents for confirmation of insurance covcratu. Abe be setts sip and data the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,net t e Deparmi A of
Industrial Accideas. Should you have any questions regarding the law or if you an required to obtain a anima'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insana.t license mamba on the awe-opiate line.
City or Tower° eek •
Please be ate that the affidavit is complete and printed legibly. The Department has provided a 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.
PIease be mere to fill in the permit/license nmsber which will be used as a mfereace number. In addition,an applicant
that must submit multiple patt/licse triplication in any given year,need only submit on affidavit indicating cutest
policy information(if necessary)and under lob Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that hu been officially stamped or=keel by the city or town may be provided to the
applicant se proof that a valid affidavit is on file fx fame permits or licenses A new affidavit asst be filled out each
year.Where a home owner or citizen is obodi ng a license or pert not related to any business or co:tsaacial venture
(i.e.a dog license or permit to burs leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would Isle to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give is a all.
Ile Depntrtnt's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oflla of Investigations
600 Washington Street .
Boston,MA 02111
Tel. #617-7274900 ext406 or 1-877-MASSAFE.
Fax#617-727-7749
Revised 11-22-06
www.mass.gov/dia
�g'Y,,� y, TOWN OF YARMOUTH
-C *! e 0 BUILDING DEPARTMENT
-4i 1146 Route 28,South Yarmouth,l'IA 02664
ta <<a:'41
508-398-2231 ext. 1261 Fax 508-398-0836
•
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BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111 S,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at So.2 ►2'' a € ye-kv,ethl
Work Address
Is to be disposed of at the following location: yiw-y„&4m`G L da y,Ae
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
iiiZgrairr /a3/is
gnature of Application Date
Permit No.
.
COMMERCIAL ONLY-BUILDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: 6-g 07 2 r a8 yort 'exY L �^^
Scope of Proposed Work: A a �� ,» �rcm `r1-aCt t,n'e mss✓ ,Scc tet/L ‘o
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Date: 7/,77 3/e .
Based on the scope of work described above,the applicant is required to obtain approval
sign-offs from the following departments as checked-off below: INITIALS
Health Dept. —508-398-2231 ext. 1241
Conservation Comm.--508-398-2231 ext. 1288
Water Dept.— 99 Buck Island Rd. phone no. 508-771-7921
Old Kings Hwy.Hist Comm.—508-398-2231 ext. 1292
Engineering Dept.—508-398-2231 ext. 1250
• Fire Dept.—Kevin Huck/James Armstrong,96 Old Main St. SY
Note: Please call Fire Department for an appointment. 508-398-2212
Other
Appropriate plans and/or application shall be provided to each of the departments
checked-off above. Each of these regulatory authorities has their own requirements
outside the jurisdiction of the Building Department. All applicable approvals shall be
obtained prior to submitting a building permit application to the Building Dept.
Thank you for cooperation.
Receipt Acknowledgem-nt:
App ' is Signature Da e
Rev. Dec. 2015
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