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HomeMy WebLinkAboutBld-20-000363 .o1•YgR BUILDING PERMIT APPLICATION T ti . $ APPLICATION TO CONS11 UCT,REPAIR,RENOVATE,CHANGE THE USE,OCCUPANCY OR ' • 14 o,e,, ii; C OR DEMOLISH ANY BURPING OTHER THAN A ONE OR TWO FAMILY DWELLING. 'c' iC6-4n. .:1\ y i Town ofY mouth Building Department �.,_,' 0 i 1146 Route ` • Irranmouth, MA 026644492 Tel: 508-398- 231 ext. 1261 Fax 508-398-0836 Office Ilse On _ /� Planrdrrg�oard Information Assessors Department Infonnati �i'"� �i � ti . .i.✓ Pin Type Permit Fee $ () - Endorseme t Date 5 019 , 1 Rem Sate w DepositRec'd. 1.4 P i ( $ � Plan No. Property Dimensions: L ,._Dig; DE P ,,t 4, I Net Due $ Other Lot Area'(sf? konta1414---_-_-=- This 4sotion for Office 1s Only Building Permit.Number: Date Issued • 7- /./7 Certificate of Occupancy Signature: is is not required t Section 1 Site Information 1-1 Property i/Vitpt.Ad.Afr. 3 1.2 Zoning Informatiorc s ,... is , Zoning District Proposed Use 1.3 Building Setbacks t) ` - Front Yard Side Yards Rear Yard Required Provided Requed Provided Required Provided 1.4 Water Supply(M.rLi.L.a.40.S 54) 1.5 Rood 21ane infarmatiorc Comments • Public Private Zone: BFE; - Section 2 Prope Ownership/Authorized i (S;1 _ PO- het- 94 10695q1i o 1 '(, Name(Pn c �+g • )R rldi 9-4'130 76.0? .)•ChA. Signature Telephone Tei. _... Acid/rs h I Email Address: 2.2 Authoriz Aged ItabA-4 ' 1(64 toltriet ‘11Za Marna Ir+ r Massing Adores /CfiVlS DOw y' ,6 39 i// `,, � a 719-7 Signatu -i 'I Telephone Fax Email Address: I Section 3-Construction Services 3.1 Uceisee nstrue tIon Supervisor. Not Applicable ❑ f f , a, License Number Address Expiration Date Signature Telephone Email Address: . / 4 3.2 Reg Home Improvement ntractor.F ,u, Connpsny'firfame Not aPP Address Registration* «- ` S n Date Signature ' Telephoner Section 4=Workers' et sation Insurance Affidavit(M.G L c.152 S 25C(e1 -, , Workers Corr>pertsaf Insurance affidavit must be completed and submitted With this iication Fl ue to providethis affidavit will result in the denial of the issuance of the building permit,,,,,,, Signed Africiiiy Attacied Yes No Section 6 P.•fattifesWoriat 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 Regkibsnild- ra►; r 0 f $ �' Ragiauon Number i Expiration tAYr` ' sl ' Telephone Section 5.2 Regis` edifei e (s Name Area of R-• g v, A _ -t. _ • ( Telephone n t Igia Area of Reeporrr l , Rlliirrber Y _ Signature Telephone egatratIon_ r 0,,.. .. Naugle • Area of Responsibility Address getratlof+Nunitw i T -1 Telephone Expiration , Arta of . "x' \. R01411, + 'Nt x Address „ Telephone Exiahlion , ry 5.3General Contractor tiontlitett,16atie f ... Not Applicable Ci 1 F �poe torCot3tn�oct , iwiteTelephone i '' 1 1 , Section 6- Desch' of Proposed Work(check aff ale) . Best Construction ❑ (for multiple family only) No.of (for multiple family ony)'No.of Bathrooms - �ting Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑ Accessory Bldg. Cii Type Demolition Other Specify: Brief Description of Proposed Work: 5ck 01(10- hes 01,noI c4ccsse fes arid 8/ja t Section 7- Use Grow and Construction Type Building Use Group(Check as a)ppfcapabie) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 (3 A-3 ❑ IA ❑ A.4 ❑ A-5 D re ❑ B BUSINESS 01 2A ❑ E EDUCATIONAL ❑ 2B ❑ F FACTORY ❑ F-1 0 C F-2 ❑ 2C ❑ m H HIGH HAZARD ❑ ©; I INSTITUTIONAL '❑ 1-1 ❑ 14 - • '''t4 3B ❑ M MERCHANTILE ❑ I 4 ❑ - a RESIDENTIAL 0 R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S STORAGE ❑ s-.t la « S-2 ❑ SB ❑ U UTILITY I] SPECIFY: M MIXED USE ❑ SPECIFY S SPECIAL USE ❑ SPECIFY' r `.-.._._. I Complete this.section if existing building undergoing.renovatimm additions and/or change in use. Existing Use Group: Proposed Use Group: Existing Hazard Index•78tl CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Bwilding'Height and Area , Building Area Existing ft applicable) Proposed Number of Doors or stories include basement levels Floor Area per Floor(st) Total Area All Floors(sf) Total Height(ft) Section 9-STRUCTURAL PEER REVIEW(7&)CMR 110 11) independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION-Ti) BE COMPLETED WHEN OWNER'S A ENT R CON CTO APPLIES FOR BUILDING PERMIT I, -wnsr_siklie subject property, ` herebyauthorize P 1.k l to act on '- x my behalf, in all matters reiati o work authorized byttisbuilding permit application. Signature , Owner ' Date Ia .,f 4 .,..�.. SECTIE '` OWNER/AUTH tS AGENT DECLARATION ='. Q • i, % �,O4 as Owner/Auth'o e ( tt hereby d are- the.statements and information on the#ongoing appiicatitm firs true a atiu> 9, the best of my Tthowledge and belief. f Signed under the pains and penalties of v Q �urY it°t) 0 ,,.. Print 4. • d/J 05 Date ' Section 11 - SIIMATED CONSTRUCTION COSTS r "' - Estimated Cost(Dollars)to be coropested by 1Ylituitairg $ 4.Mechanical(HVAC) - , - U. . 5.Fhs Natal:DWI 6.Total in(1+2+3+4.+5) ? C- Ring t' /j( In 0 Old angsa 1 H Beal Cortutn xoval (if0. - c k,vf d , -- -. _ - -01 • _ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 11_ Boston, MA 02114-2017 r;5�•'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): ����e Q roa. Address: 5-q a i)\(; )-\re, c V City/State/Zip: wes �(11'l'm OU . tAA Phone #: - Are you an employer?Check the appropriate box: Type of project(required): 1.0 l)wra employer with employees(full and/or part-time).* 7. ❑New construction 2 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp. insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.['Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.0 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. tContractors 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: 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u er he pains and penalties of perjury that the information provided above is true and correct. Signature: ,G' Date: oS/D /19 Phone#: Cj ! (s-0 3 - % 7 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 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. _ Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building 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 agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s), address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. 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 insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure 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 has to contact you regarding the.applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia Q' T TOWN OF YARMOUTH ;yg BUILDING DEPARTMENT E. ` MA Route 28,South Yarmouth, A 02664 st? 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOL ION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter I,Section 54 and 780 CMR, Chapter 1, Section 111.5, I hereby certify that the debris result: g from the proposed work/demolition to be conducted at Work Address Is to be disposed of at the following Iocatio : Said disposal site shall be a licensed solid waste :cility as defined by M.G.L. Chapter 111, Section 150A. Signature of Application Date Permit No. M FIRE TOWN pF yARM Ol1TH ;0) kifki ,it. REVIEWED FORGL CODEAND COMPLIEVE LIANE. ERRORS OR OMMISSIONS DO NOT RE THE APPLICANT FROM THE RESPONSIBILITY : OF"AS BUILT"COMPLIANCE. DATE:-c-LiaC9 lL� CA, f YARMOUTH FIRE PREVENTION INSPECTOR �-� • — New Business Transmittal Project Name: Charm Cape Cod Address: 572 Route 28 Unit 3 Contact Name: Bruna Chaves Cobral Phone: 774-368-3046 Y N NA Subject Regulation ES O X Building Numbers MGL Chapter 148;sec 59 X Fire Lanes 527 CMR 1;22.3 X Extinguishers 527 CMR 1; 13.6,Chapter 148;sec 28 X 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 Extension cords shall not be used as a 527CMR1 11.1.7.6, 11.1.7.1 X substitute to permanent wiring X 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: The YFD support the application, subject to applicable submissions,permits and inspections. A Permit from YFD is required any time a fire protection system is shut down. * YFD permit required-depending on occupancy and submittal Plan Reviewed By: Captain Kevin Huck Date: 05-16-2019 Copy for Applicant 0 Copy to Building Department Copy to Fire Prevention Entered in Firehouse Ti Final Inspection °t:= TOWN OF YARMOUTH `'1 lib HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: .5-3 a. kv'iC oZ ; j n i ' Y1° 3 Proposed Improvement: 5o t-c 0 Y w w r, S C',1 u M^r Q a c cesso/;r s Applicant: )0.3 cp,rAf cbsfJY`q (COWID 66104 Tel. No.: .? Address: 1 p(‹, u 9e/11/46C1) Uy I c p Z ' Z Date Filed: 05/ 03 **If you would like e-mail notification of sign off,please provide e-mail address: ) -e ' Owner Name: V QQ\ C,r,hcvdS l 9.34 530 964 Owner Address: PO OO e d , E S s g : .MA- )9 2 9 Owner Tel. No.: '' '-" c Z 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: DATE: <13 !' PLEASE NOTE COMMENTS/CONDITIONS: y • a 15/07/2019 (27)WhatsApp You p '* A + • X ., 7/12/2019 at 12:43 PM r ' r rr r 1 r,,,rr r;r r,' 1 ' r ':rr rr,„r:r,r:'Of 0". .':'":::r r:r f:,.,4 r,,T,.:.11''rr,.;.'rr., -414 .i3;:.:4:!;,111 S Q_+k,i'Ir , Er .sd z�'� r H r k ,, � , \ y..x... k • https://web.whatsapp.com