HomeMy WebLinkAboutbld-20-001464 14et.i.k t-it+- -On • i, iz r F., i V b
, , !. .
7 1
.•
• • • of Y. q.c.. BUILDING PERMIT APPLICATION ._ L..„‘ __ ._
APPUCATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE.OCLIJP62,0Oi d',_ .f--'-'AN_T.
.... • , ' „ , ' '" OR DEMOUSH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY D
Town of Yarmouth Building Department
tliztr.:c.5,10;
I 1415 Route 28 - Yarmouth, MA 0266-1-1492.
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836
Office Use Only Planning Board Information Assessors Department Infant:am
i a it Ne -0 -CD/4/67atti Plan Type Map lAt
Permit Fee $
Endorsement Date // -30
. ft-0
Recording Date
Deposit Rec'd. $ U Date— Plan No. 1.4 Property Dimensions
Net Due $ Other txt Area(sf) Frontage(I) Lot Coverage
Building Permit Number This Section for Me Use Only
Date Issued:
si ,,,, , ,4 7-7,77,47 . Certificate of Occupancy
Official Debt is Is not required
-
Section 1 -Site Information
1.1 Propirty Address: 12 Zoning informed=
9 W hastn S‘r t
S.Nei ton_c trkh I MA csabto4 Zoning District Proposed Us.
1.3 Dullellose Sotbaoks(1%) •
Front Yard Side Yards Rear Yard
Required Provided Required
I Provided Required Provided
1.4 Water Supply(14.04.0.40.S 54) 1.5 Rood Zone irdormetiort Comment=
QC> Private Zone _ SFE: •
__
Section 2-Property Ovmership/Authorized Agent
2.1 Owner of%icor*
RN‘eir‘endir, tont-tar-ken+
Name(print)
CUIL-Sow-1/4_0Q81.4m..• 81-14(10-4-114-11
. -
?0 box ';,.3 TocesiclakeMA ouctiLl
Mailing Address:
Signal:m0 Telephone
Telephone
N 2.2 Author! -• Agent Email Address: .7
.....---
1 .4 440/_ • e ,/. IP 0 . 3' AY -714--&/' ,lit4e. 0. I )
ado Name(print) • ,
Mailing"Allie:::4/.)16 A
SignatU
Telephone Fax 96/ tfi
- I
Email Address: -I\
Section Con • Wats ,
3.1 Lite sad Construction Supsrvison Not Applicable 13
License Number
Address
Expiration Date
Signature Telephone Email Address:
•
,
• :, Section 6-Description of Proposed Work(check all applicable)
New Construction CII (tor multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms
Existing Bldg. ( Repairs) ❑ Alterations CI T Addition ❑ I No wok A Ao lap 4,43, mea
Accessory Bldg. ❑ Type Demolition Other S1Rectf--
Brief Description of Proposed Work A
APT/C e / G e# 't
Section 7-Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
• A ASSEMBLY I❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-S D is ❑
a auSNESS V 2A ❑
E EDUCATIONAL ❑ ❑
F FACTORY ❑ F-1 ❑ . F-2 ❑ 2C ❑
H HIGH HAZARD O 3A ❑
l 1NSTTTUT)oNAL ❑ I-i ❑ i-2 ❑ b3 ❑ 313 ❑
M MERC2-IANTILE ❑ 4 ❑
R REsioeiNTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA VS STORAGE ❑ S-1 ❑ S-2 ❑ 5
U Lrr1LnY ❑ = SPECIFY: „�
M MIXED USE ❑ SPECIFY
3 SPECIAL-USE ❑ SPECIFY:
Complete this.section if existing building undergoing.renovations:additions and/or change in use._,
Existing Use Group: isropoged Use Grog
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 qIR 34
Section 8 Building Height and Area 1
Building Area Existing(if applicable) Proposed
Number or floors or Stories
include basement levels
Floor Aces 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 1
ISECTION 1 Qa OWNER AUTHORIZATION-TO BE COMPLETED WHEN t
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT}
I, A11i _in 41ughGn /A1ltn5er\ t1nr�.,.,..�._....�
J ` '^""' . as Owner of the subject property,
hereby authorize N E L C.OrporQ,}icr
my behalf, in all matters relative to work authorized by this building permit application. to act on
Signature of Owner (� i"��Iq
Date
The Commonwealth of Massachusetts
D artmt of Indasn' Accidents
�`+i►k_•" 1er Congress Street,Suite 100
=1`i_ • Boston,MA 02114-2017
ww►kmass.goWdla
%ricers'Compensation Insurance Affidavit:Builders/Contractors&Electrlefans/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY. Beane Print LOEWY
Aoolicant Information ,r
Name(Bus iness/Orpaixttion lndividusl): /Y FLCr a A**Off•
Address: 4)004►c 1 WdtL(
Ci /stateizi : ' ,*AOt1W Phone#: 7 '?TT'��
tY P
Are you an employer?Cheek the appropriate box: Type of project(required):
am'employer with 120 empbyeea(MI and/or part tlme).' 7. 0 New construction
2. I am a sole p oprieta or peitiaahip and have no employees waking for me in 8. Q Remodeling
any apecity.[No workers'gyp-insurance requital] 9. Q Demolition
3.0 I am a homeowner doing ell work myself[No workers'camp.insunmee required.]t 10 Q Building addition
4.0 I am a homeowner sad will be hiring oadracton to conduct aft work on my property.I will
now.that all corsractom either have waters'compensation Warm
an are sole 12.❑Electrical repairs or additions
p10Rieten with no employees. 12.❑Plumbing repairs or additions
•
3.0 I am a general coaraaor and I have hired the anti-ooatreaors listed on the amched sheet 13.Q Roof repairs
mew sub-co have employees and have workers'cramp.inuutoe.t
6.0 We are a oorporetloe and its officers have amraised theirrIgt*of exemption pa Mtii,e. 14.Q Other
152,f 1(4),and we have no employees.[No voodoos'camp.insurance required.]
Any'optical dada bout!mutt also fill out the section below showing their tatters'compensation policy information.
t Aaneowners who submit this a fidevit indicating they are doing all work and then bins outside contractors must submit a new affidavit indicadng such.
tContractots dint check this box mutt embed an additional sheet showing the nano of the subcontractors and state whether or not those entities lave
Miss sub-cc uraeonahave employees,they must provide their wauts'ln camp.policy mober.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site
b formation.
Insurance Company Name: C4- 6 Q 1 AJ 1 C 14^! w T' INS 6,
Policy#or Self-ins.Lic.0: 541307699 Expiration Date: 6 - 02 O
Job Site Address: '1/A 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 MOL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
verification.
I do hereby ceritJ i der es of perjury"that the Information provided above is true and correct
•
_ _ _ .
use only. Do not write in this area,to be completed by city or town official
iciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1,Board of Health 2.Building Department 3.
6.Oth City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
•
Contact Person•
Phone#:
IMIIIIIIII"1111.11111111111111111111.11111111111.111111.111.111111111111111111111.1111.1111.1111.111111.11:_________ ___ ___ __ .._ _------ — _ _. _ __ —________ _ ____ - - - . _ _
jSECTION 10b OWNER/AUTHORIZED AGENT DECLARATION I 'M
j /►�!(C t_ 5- ' y 5VAISS ,as Owner/Authorized Agent
1, l�E
hereby declare that the statements and information on the forgoing application are true and activate,to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Ak C6A-EZ-- -S-• AN-LASSC
Print Name
- / 1 ix , _ .5- , 7
Signature of Owner/Agent Dal
Section 11 -ESTIMATED CONSTRUCTION COSTS
nem ' Estimated Cost(Hats)to be
completed by permit applicant
L Becalm!
3.Plumbing/Gas
4.Msdtarrnl(HVAC)
5.Fire Protection
\t • .
a Total-(1..2+3.a+5)
7.Thal SQuere Ft mirowswasom t asleep
Check Below
(3 Conservation-Commission Filing
(d applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
TAQO FO
4::
° Tyco��qa vT
444.FRF N0 7F y
YARMOUTH FIRE PREVENTION T oNsiBlye
New Business Transmittal o
Project Name: NEL Corporation Address: 9 North Main Street Unit#
Contact Name: Michael Garasso Phone: 978-777-2085
IY N NA Subject Regulation
ES 0 I
x Building Numbers MGL Chapter 148;sec 59
Fire Lanes 527 CMR 1;22.3
Extinguishers 527 CMR 1; 13.6,Chapter 148;sec 28
Maintence of any equipment,system relating to 527CMR1 1.1.4
Fire Protection.
x *Hazardous Materials Storage 527 CMR 1;60.1
x Emergency Plan Required 527CMR1 10.9.1
x Commercial cooking,Hood systems 527CMR1 50.2.1.1
x Commercial Cooking Hood Systems Cleaning 527CMR1 50.5.4
x *Commercial Cooking Extinguishment System 527CMR1 50.4.3
x *Candles,open flames,and portable cooking 527CMR1 17.3.2,20.1.1.1
x Blocking electrical panel 527CMR1 10.19.5.1
x Blocking exits 527CMR1 14.4.1
x Extension cords shall not be used as a 527CMR1 11.1.7.6, 11.1.7.1
substitute to permanent wiring
Limit storage heights to 24 inches below 527CMR1
ceiling without sprinklers 18 inches with
x Maintain Aisle width of 36 Inch's(3 Feet) 780CMR 1101.1
x Storage inside/outside Buildings 527 CMR 1; 10.19.4,4.4.3.1.1,19.1.2,34.1.1
x The right to inspect MGL Chapter 148 Sec.4
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
Description of planned project/other requirements: Business Use Only!!
* YFD permit required-depending on occupancy and submittal
Plan Reviewed By: Lt. Scott A. Smith Date: 9///f
Copy for Applicant 0 C py to Building Department Copy to Fire Prevention I .
Entered in Firehouse Final Inspection !
• Act"RO� CERTIFICATE OF LIABILITY INSURANCE DATE
g/M/20109 Y)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
The Driscoll Agency, Inc. PHONE Peggi Buckler FAX
141 Longwater Drive A/c.No.Exti:781-681-6656 (NC,No):781-421-2479
Suite 203 ADDRESS: pbuckler@driscollagency.com
Norwell MA 02061 INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA:Executive Risk Indemnity Inc. 35181
INSURED 217151 INSURER B:Federal Ins Co 20281
NEL Corporation INSURERC:Chubb IndemnityIns Co 12777
3 Ajootian Way, Building B
PO Box 929 INSURER D:Starr Indemnity&Liability Co. 38318
Middleton MA 01949 INSURERS:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2131543521 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP
INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
A X COMMERCIAL GENERAL LIABILITY 54309698 6/4/2019 6/4/2020 EACH OCCURRENCE $2,000,000
CLAIMS-MADE X OCCUR DAMAGE TO RENTED
PREMISES(Ea occurrence) $300,000
X Contractual Liab MED EXP(Any one person) $10,000
_X XCU PERSONAL&ADV INJURY $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000
POLICY X JECOT LOC PRODUCTS-COMP/OPAGG $4,000,000
OTHER: $
B AUTOMOBILE LABILITY 54309697 6/4/2019 6/4/2020 (Ea aadentSINGLE LIMIT $1,000,000
X ANY AUTO BODILY INJURY(Per person) $
OWNED X SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
x HIRED X NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident) $
$
D UMBRELLA LAB X OCCUR 1000584514191 6/4/2019 6/4/2020 EACH OCCURRENCE $15,000,000
X EXCESS LAB CLAIMS-MADE
AGGREGATE $15,000,000
DED RETENTION$ $
C WORKERS COMPENSATION 54309699 6/4/2019 6/4/2020 X PER OTH-
AND EMPLOYERS'LABILITY YIN STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBEREXCLUDED? n N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Town of Yarmouth is included as Additional Insureds for Automobile Liability on a primary non-contributory basis for the conduct of the(Named)Insured,but
only to the extent of that liability.
Town of Yarmouth is included as Additional Insured for General Liability and Excess(Umbrella)Liability,for ongoing and completed operations,as required by
a signed written contract or agreement with the Named Insured.
Notice of Cancellation provision is 30 days except 10 days applies for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Yarmouth
1146 Route 28 AUTHORIZED REPRESENTATIVE
South Yarmouth MA 02664
Aiatis je ,)/4;e., ,7
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
. RECEIVED
se Y'1k TOWN OF YARMOUTH
{/ 0 HEALTH DEPARTMENT SEP a 6.2019
si 0 " j - y� HEALTH DEPT.
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: \
Building Site Location: 9 )i 9/i2. eJL/i' _ Q L/V . p
Proposed Improve ent:
1a - ----ei
Applicant:01 erp1 a ( 'V' l'riej cd r5DdtjTel. No.qw'rf77 �S
Address:345OO—F044Ii 8� ' 3 /, tipdh*di ate Filed: 9''70— rq
)-4)41- Aoi v/9
**If you would like e-mail notification ofsign off please provide e-mail address:
Owner Name:4/-&//2rai );k M(_ Ai j A
Owner Address:?O, 3 ) 5 3 ),c e hog- Owner Tel. No.:SW.,- 7(i -qr?7
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
q /i/. A&. I ✓-) For Septage Disposal and other Public Health Activities.
npa(
1 �fr-- Please submit three (3) copies of plans, to include:
T I (1.) Site Plan showing existing buildings, water line location,
.t -- and septic system location;
OF°i it (2.) Floorplan labelingALL rooms within building
� ,;
bot� (all existing and proposed) —
t. S i Note:Floor plans not required for decks,sheds, windows, roofing;
r' are (3.) If necessary, Title 5 application signed by licensed installer
iace p h D rt with fee.
REVIEWED BY: DATE: / J;21.i )C1'
PLEASE NOTE
COMMENTS/CONDITIONS: