HomeMy WebLinkAboutBld-19-007211 i • 5 •
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.QI.V.. 4? BUILDING PERMIT APPLICATION
• . ..��4ro APPUCATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE,OCCUPANCY OF,
"t„ c OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
' F ���� Town of Yirntouth Building Department
! 146 Route 28 i Yarrncmth. MA 02664-64512-
,.
Tel:
50&398-2Z3I ext.'1261 Fax 508-398-0836
Office Use Pig Board information Assessors Department Information:
sue' NI ate Type map
Permit Fee $ qc2
a
RDeposit Rec'd. $ Date plan t>atf IA Property Dimarsront New
Net Due $ Outer Lot Area(st} Frontage(It) Lot Coveys
nits Seiko for Once Use Only .
Building Permit.Number: Date Issued: -
-"Dt V -1 Certificate t . t wee+.+ '""—_----
✓/ (� 4
Buildingilictel Date- is isSection 1 Site Information I " i i
< 1.1 Property Address 1.2 Zoning Informa�irc WS/674
41a eTZS f
ei iLDI' Gy OEPARTME '.
Zoning District Sy.
1.3 Building Setbacks(ft) '
Front Yard Side Yards Rear Yard.
Required Provided Required Provided Required Provided
1.4 Vio4or supply(mai e.40.S 54) 1.5 Rood Z s irdor neiort Garment=
Public Private " Zone: ._._ BFE;
• Section2- Property Ownership/Authorized Agent
2.1 Owner of ttoleords V4,Y d+
i Nr�i1pc/ 412 n'3i1s-. ter, Ci t
f
titr: AA .:1,i l Ni Tk�
. Ne?i;i1r414y, Mailing Address: .•'
5 -z -Sri £ -?BO -0%e4,7
Sigma, .-' Telephone Telephone , I
Email Address:
2.2 Authorized Agent:
i../Lt l ois - - ®0 1.4 3- 41. r Co. 1Xt5?fl thierit_CAA ran
r' ;: Mailing Address: r
*titnagtaii I 5.0 43z- oho
A Telephone Fax Email Address: 1
Section 3-Constructor) pA°U r @ co nk-b0Or.Cam
3.1 Licensed Construction Supervises Not Applipatie Li
1 eat€ — Ri)bn4 B t Q + CS Q q,a io
License Number
?OJo 1501 -LALl /l C, ; Vitr CAS
A.. 0tJ
e�/ 1SL S— ��t�►'OkaPt�UdC_ Expiraton Date
- use Telephone J Email Address:
...
o
t., o vement
comoovits .
y T > - k V '
'., 4-_Y 'tters' InsuranceAffidavit(M.G.L c.152 S 25C(19 ..0 ,s
Juicers Compensation Insurance affidavit must be completed and submitted with tf
provide this affidavit wiU cra it in the den of the issuar+ce of the buck l i ng permrt.
Signs d Affidavit Attached Yes ..... No
1Pic"ticn.'
,r,
Section 5-Profe tat Design and Construction Services-for Buildings and StFuctu s�=
to Construction Control Pursuant to 780 CMR 116(containing more than 35.000 c t of i i spas)
Section 5.1 R-.,,-._.._; A
NotAavicabm❑
i
Nam 1 $ Reglotteko#luirter
.igid&eills
Signal* - Telephone
►ti !9or'2�`^aey���1 -Ji ems ! ���I', __' CAI - J , •
Air of .
Address RegistndlonlhOltolt
Telephone Expiration Date
Nertno
Ales d Arpon eRy
Adckeee Registration tikx ter -
aOw
x
Mona Allot d -rr- ..
4
Aims
T
Address
f
Sigtaturt Telephone
Section 5.3 General Contractor
o �'i. .
+s•'1 _
6 Ang
SitInshill., . Telephone
l
C
• 1 rt,- S:tion 6- Description of Proposed Work(checllk al app8cable)
•'. r ' New Construction ❑ (tor multiple family only) No.of Bedrooms_ (for multiple fan*only) No.of Bathrooms
•'; Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Dernolftion ,, (ii4Other Specify:
Brief Description of Proposed Work:
CILVM ct-- 611,5 Ftet, r9 li ) szirimAAn ca plan. 1
-ELA,t U. (43' 4-- tO '
Section 7- Use Group and Construction Type
Budding Use Group(Check as aPplcapabie) Construction Type
• A ASSEMBLY ❑ A-1 ❑ A-2 0 A-3 ❑ 1A
A-4 Q A-5 ❑ 1B ❑
B BUSINESS ❑ SA 0 i
E EDUCATIONAL ❑ 28
F FACTORY ❑ F-1 0 • F2 D 2C 0
H HIGH HAZARD ❑
4.
I INSTITUTIONAL ❑ I-I ❑ 1-2 0 I-S 0 39 ❑
M MERCHANTILE ❑ 4 (]
R RESIDENTIAL ❑ R-t ❑ A-2 ❑ R•3 ❑ 54 ❑
S STORAGE ❑ S-1 ❑ S-a 0 as 0,
U UTILITY ❑ SPECIFY
M MIXED USE ❑ SPECIE
S SPECIAL USE ❑ SPECIFY: .4
Complete this section if exfstkig building undergoing.renovations additions and/or changeiri use.I
Existing Use Group: Proposed Use Group: •
Existing Hazard index 780 CMR 34 . Proposed Hazard Index 780 DAR 34 _ _
Section 8 Building Height and Area
Bucking Area Deleting trf applicable) Proposed
Number of floors or stories
include basemerd levels
Floor Area per Floor(sf)
Total Area All Floors(sf)
Total Height(ft)
E
Section 9-STRUCTURAL PEER REVIEW(730CMR 110 11)
Independent Structural Engineering Structural Peer Review Requited Yes No
'SECTION 1 Oa OWNER AUTHORIZATION-it) BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLES FOR BUILDING PERMIT
I, # )card ah E'Y�- as Owner of the subject property,
hereby authorize { - ' 2e1?X-
- to act on
my beh ' - , - - ' -tie to work authorized by this building permit application.
L 1 4 ()till tIl IDlq
Signature of Owner ate
•
Nw.
i l Ottifbitifiti AUTHORIZED AGENT DECLARATION I
(J( b4 ► IL- tkit)(` �,�: QLA •
as Own.aff d Agent
Pre
retWillirA- arethat the statements and information.ot the-forgoing application are true and acurate,to
the be _` ten . .
midge and belief.
Signed under the pains and penalties of perjury
4
( ��i12,,c
.Prk,t Nairn. _
, 0(12'- 1 1 -1:9 --';'----
Section 11-ESTIMATED CONSTRUCTION COSTS
item •` Esaemed Cost(Ddws)to be
ccqnpleted by permit applicart
Building
a ElaetrkiR
3.Plimiibinci/Gas
4.MedrsrMeal(HVAq
S.Fee Pr*t*Ctlan
B.Tota1:(1+2+3+4+5)
• 7.Toad square FL'Osrmeriaa+�a IIeeaimN l t V(-.)
Check.Below .
0 F
• d Oid'
Comnsission approval
(lt applicable) •
•
•
•
The Commonwealth of Massachusetts
a _ 1 Department oflndustrialAccidents
- atI- 1 Congress Street, Suite 100
•_i•mow
t. Boston,MA 02114-2017
• • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information � �*� CO ^� Please Print Legibly
Name (Business/Organization/Individual): �-��J`-„'� ? -(�`)'{ CO ' v)c.
Address: 24 C—]Tpz-lv QA ec r 1" 1
City/State/Zip: �Cf 1 ' r'j (`�?fnu Phone#: Crad {c`�2�O O
Are you an employer?Check the appropriate box:
,.� / Type of project(required):
l.' lyam a employer with `�Omployees(full and/or part-time).*
----tttCYYYY 7. New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling •
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work myself. t 9. Vmolition
❑ y [No workers'comp. insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on m Yproperty. I will 10 El Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5.11 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.t 13.El Roof repairs
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy 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-contractors 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: .)ec C
Policy#or Self-ins.Lic.#: C)pA 6310-01-IS Expiration Date: 1'1
Job Site Address: 4 cZ O\E 7--% City/State/Zip: {'rY) (Y)0.-0UP-.
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as well ., civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy oft ' atement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify u laze •: ns a `penalties of perjury that the information provided above is true and correct.
Signature: Date: 01 Ul t 9
Phone#: ��� ' 3Z'OS-3 b
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#:
RECEIVED
se Yiik TOWN OF YARMOUTH
• ,IUN 172019
HEALTH DEPARTMENT
r ," HEALTH DEPT.
„.& PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEE l
To he completed by Applicant:
BuildingSite Location: 28 C� ✓ V-e ���5 ��'���'"
Vga? "--Flyr . U U
Proposed Improvement: -- LMo C ?cv r J/(...,h)i(/�
c`z� a �2 �'.� . �e�� l�u��s .gad-���o ,7/3�-0�0
Applicant ( / Tel. No.
Address:V C rf, Jeri o 76. hhic-One M9, Date Filed:J�0/Q /9
**/f you would like e-mail notification of sign off please provide e-mail address:
Owner Name: 17)j /-XL.A/A,K5
Owner Address: y/L /'W1 i J J� - ii. y471��N�f�J rf/(q, Owner Tel. No.Oct- Z80 •oC 7
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: 9r12 DATE: 17 f
PLEASE NOTE
COMMENTS/CONDITIONS: /')v
e--C 0 w - r,2J ✓ J".•. K tcA-,k4171MEIZIEl A- 5 S. 64 v 5
- ..
•
n •X TOWN OF YARMOUTH
BUILDING DEPARTMENT
;� „�7 V.
� 4 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext.261
ti BUILDING DEPARTMENT
TOTAL DEMOLITION SIGN-OFF FORM
State Building Code(780 CMR)Chapter 33,Section 3303.6-Service Connections
"Before a building or structure is demolished or removed, the owner or agent shall notify all
utilities having service connections within the structure, such as water, electric, gas sewer and
other connections. A permit to demolish or remove a building or structure shall not be issued
until a release is obtained from the utilities, stating that their respective service connections and
appurtenant equipment, such as meter and regulators, have been removed or sealed and plugged
in a safe manner."
"All debris shall be disposed of in accordance with 780CMR 111.5."
Building or Structure Location: LiCka (,f'1< Map: Lot:
Owner's Name: Address: Phone:
Contractor's Name: Address: Phone:
Eversource: By:
NJ iN
t-- l� tl�, �-
Y tl
Title: Ak^C C
National Grid: Date: N j
By:
Title:
Water Dept.: Date:
By: 14T
• Title:
i I �
Board of Health: Date: � ' 13 ��� �{ - ` e 7
By: 4.�t t4 -a 4
Title: o- ' / I
T
Condition: l? t w)�`�' tv to A,4-t.,a,t �� r
Fire Dent.: Date: &4 //7
Title: ( di. �� �'t',(I�
l,,c i„r5` r, a ,G
Historic Commission: Date:
By: N/A
Title:
Conservation: Date: NA k By:
Comcast: Date: t\i/‘
3/15
graillif alba
BLIallar
REILLY ELECTRICAL CONTRACTORS,INC.
110 Old Townhouse Rd.-So. Yarmouth,MA 02664
508-771-2040•888-GO-RELCO-FAX 508-760-1425
July 9,.2018
Mr.Joe Marrama
Cape Cod Family Resort
518 Rte.28
West Yarmouth,MA 02673
Re: Cape Travelers Motel
Bldgs.Demolition
492 Rte.28
West Yarmouth,MA
Dear Joe,
All power, telephone and CATV services to the existing four rear housing bldgs., Rms. 5 thru 30 and
pool house at the rear of the property have been disconnected in their entirety. From an electrical and
communications systems standpoint it is safe for the demolition and removal of the subject structures.
Please consider additional utilities such as water, sewer and gas as well as contacting Dig-safe prior to
demolition and excavation.
Should you have ay questions and/or concerns,please do not hesitate in contacting me at any time.
Yours Truly,
Scott A.Ventura
Director of Operations
Ltr.Cape Travelers Demo
Electrical Contracting•Design•Service&Maintenance
• „„
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0 ' '`' ':� TOWN OF YARMOUTH
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} BUILDING DEPARTMENT
1146 Route 28,South Yarmouth,MA 02664
o,,.:0 •s• 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 ;'i qp C19� I
Work Ad ress c c d CAC-bat
Is to be disposed of at the following location: Conextekdi-
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section.450A.
4,4/_ ,'ham e
Signature , iffl1 licad 17 Date
Permit No.
/ .
Commonwealth of Massachusetts
L Division of Professional
al Licensure
and Standards
Board of Building 9AI4� rvisor `;
Consl i; ;-
4!p i res:0610312021 F
CS-092761t .;
ABIGAIL O RpSE
P.O.BOX 1619 j '
HARWICH M1fi/Q2f " i i. N
Commissioner 't I'r