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HomeMy WebLinkAboutBld-20-000390 ,.., { Q ' '• ..: of•-rqR BUILDING PERM APPLICATION •`. I.: • . k� 4 APPLICATION TO CONSTTRUCT;REPAIR,RENOVATE,CHANGE THE USE,OCCUPANCY OF, • . irlii G tY � C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. to 4, Town of 1 trnlouth Building Department c6474+7.7", 1146 Route_'li • Yarmouth, MA 02664—I492 — Tel: 508-398►2231 ext. 1261 Fax 508-398-0836 _ Office Use On, Planing Board Information Assessors Department Information: Pertr 4& 40 tVD w Plan Ty ri tor . Permit Fee $ / Endorse Date //o /5 hh Recordin¢Date IYew Deposit Reed. $ V Date plan fro. 1.4 Property Dimension` Net Due $ Other „ Lot Area(st) Frontage(ft) Lot coverage • • This Otadott for Office Use Only • Building Permit Number: , Date Issued: signature: Ce`titi of Occupancy Olilsiat Data• in_^-_.—a not requited Seclkm 1 -Site Information 1.1 Proparty Address 1 1.2 Eoning Information: O . )f i eneA44h ina. a�4;6 4' Zoning District Proposed Use la RRulldRng Setsaa t(It) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.4 Water Supply MULL ca.40.S 54) 1.5 Rood Eons Wnnralfon Gram ma -N. . Public Private . Zon: BFE: • Section 2- Property Ownership/Authorized Aient 2.1 O7of R Pe�N 336 I fit s4 ;�/.FI N tl�ir+h'' � � �iling ��� Af'�� / f.` Signature Telephone Telephone _ s Email Address. - 42 Authorize liklinstdarint) 1 fk ou'aiiff 64(troo,j-x . g. j3 cuAlly.c Ath &01 Mailing Address: .. Se-gr1 C4/f5 rUsc S4r 'a,ie, (vs f (dr7 Signature Telephone, 1:< , Fax Email Address:. j • Section 3-C Services 3.1 Licensed Construction Superrvisear•----- _— Not Applicable r-- - 4104 License!Unbar Address �r 1 1m 1 y B U I t*r_: D L I-a .t, [_;4; ; Expiration Date Signature Tel ':,, — �;;�•ceail:.A�ddress: I 3.2 Reg➢shiired, ltpravement Contractor. moo. -��" r�Apace „Company Kantre. r _ Section 4=.Woticeter(l �sation Insurance Affidavit(M.G.L c.152 S 25C(6-) , Workers.Conipensation 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 Bungs and Structures Subject to Construction Control Pursuant to 780 CMR 115(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Architei Not.141Plitable 0 1` Registration Number . Address . Expkation Den SIgtvature Telephone Section 5.2 Registered Professional Engineer(s) • Manse Anus of Responsibility Address Registration teurrber Signature Telephone Expiration Date / Area of Rasponskality Address R.yfasnifon Nuiribrat Telephone erPirstbn 0 Iiiiiilleei e • Area of Respors6Mly j Signature Telephone aillitaibn D I • Area of Responsibility ra�arar.. � - Ifiittifilt- \. 'Registration number Telephone Expiration Dais Section:5.3 general Contractor , Notftpp5cable 0 Comply Neon Person Responsible fot Construction Address 1 Signature Telephone 1 I • • • fir►. Section 6- Description of Proposed Work(check all applicable) New Construction 0 (for multiple family only) Na of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. 0 Repair(s) ❑ Alterations 0 - Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: Brief Description of Proposed Work: (Si v ret(Pe Atzfrc _ p/mo,t //,1•41 /4-4-Cci?e,..)‹.64.) Section 7 Use Group and Construction Type Building Use Group(Check as applcapable) Construction Type • A ASSEMBLY ❑ A-1 ❑ A-2 (] A-3 ❑ to ❑ A.4 ❑ A-5 CI 1B ❑ e BUSINESS p zA 0 E EDUCATIONAL ❑ 313 ❑ F FACTORY F-i F-2 H HIGH HAZARD ❑ 3A I] I INSTITUTIONAL ❑ i-1 ❑ I-2 Q I.3 0 3s ❑ M MERCHANTI(:E ❑ 4 E3 R RESIDENTIAL d R-1 ❑ R-2 ❑ R-3 ❑ 5A 5 STORAGE ❑ 5-1 0 5 2 ❑ se ❑ . U UTSJTY SPECIE\" M MIXED USE ❑ SPECIFY; • S SPECIAL USE laspecwi I Complete this-section if existing building undergoing.renovations;additions and/or change in use-1 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 Esislir (rf applicable) Proposed Number of Room or stories include basement levels Floor Area per Floor(sf) Total Area All Floors(s Total Height(ft) - Section 9 STRUCTURAL PEER REVIEW('78OCMR 110 11) Independent Structural Engineering structural Peer Revliw Required Yes No SECTION 10a OWNER AUTHORIZATION`-TO BE COMPIETFD WHEN • OWNER'S AGENT OR CONTRACTOR APPt.IES FOR BUILDING PERMIT- i, : . as Owner of the subject property, hereby authorize 41 5 e t9 /�% hker l 1/fit to act on my behalf. in all matters relative to work authorized by this building permit application. Signature of bwne Date ,SECTION lOb Ii4fili AUTFIORIZED AGENT DECLARATION • I, k1 Ce(/j/.-►a as Owner/Autho#f id`A hereby declare that Ittel statements and information on the forgoing application are true and acurete.<to the best of my k thwledge and belief. Signed under the pains and penalties of perjury. Print re . ,._ . 7 /''')1 _ _ Section 11 -- :*ED .•NSTRUCTION COSTS Cost(Dollars)to be convieted 1.Buffing bypermit applicant a Electrical &Plumbing/Gas 4.&*ed* lc t( NAC) 5.Fire Protraction 5.ibis!.(1+2 4.3+4+5) - 7.Total Square Ft.Pram'mesons ia OWN* Check Below 0 Filing -" ) 0 Wilting*ay a HI torical corntrdeitiort approv l • I 1 1 The Commonwealth of Massachusetts , Department of Industrial Accidents 1 Congress Street, Suite 100 47 Boston, MA 02114-2017 ,� •'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly N(...,,ame (Business/Org//anization/Individual): 54-• 0a���/ (3 0$ LLC Address: J 3 ,14..s i,1-- it)- City/State/Zip: 50, ?/4-7414 MG. 0-60hone #: sal G f/cF Are you a employer?Check the appropriate box: Type of project (required): 1. am a employer with / employees(full and/or part-time).* 7. ❑New construction 2.1:1 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8. Remodeling 3. I am a homeowner doing all work myself. t 9. ❑ Demolition ❑ y [No workers'comp.insurance required.] 4.❑ my I am a homeowner and will be hiring contractors to conduct all work on 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.❑Plumbing repairs or additions 5.❑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.; 13•❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Qtller 152,§1(4),and we have no employees. [No workers'comp.insurance required.] /r *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:/1,5-CO C/a/'•PJ 1 ii/i 4P Policy#or Self-ins.Lic. #: A.K C $T6Z J 6 /F-2 a (.2 d/ g Expiration Date: /g-0/ 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 coveq.ge 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 c tify under the pains and penalties of perjury that the information provided above is true and correct. gnature: /y S Date: 7 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. 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-contractor(s)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 . PLEASANT ACRES, LLC June 17, 2019 Mr. Steve Bobola EMAIL DELIVERY Mr. Rob Warren SAND DOLLAR CUSTOMS, INC Unit G2 23 White's Path South Yarmouth, MA 02664 (774) 353-6805 RE: Unit D, 389 White's Path, Yarmouth Dear Steve and Rob, I am happy to welcome your company as a tenant-at-will of Unit D at my 389 White's Path property. You come highly recommended by Brad Inkley. I understand that you operate a construction company remodeling and building custom homes. You have an office at the other end of White's Path and will use Unit D for storage and some fabricating. On Saturday Steve met with Brad and inspected Unit D. Currently, the Town does not allow any vehicles or petroleum products to be stored within the units because the property is located within its Water Resources Protection Area. A former tenant had dumped gasoline down a floor drain that lead to a leaching catch basin that used to be in the front parking lot. The groundwater was contaminated, and the property was listed by the DEP. On May 4, 2019, I was able to submit the required documentation to have the property removed from the DEP's list of hazardous waste sites. You will have to register your use with the Town. On June 26, 2014, I purchased the tax title, contaminated property from the Town of Yarmouth at a public auction. In November 2015 I received a favorable judgment from Land Court. The building has been neglected for several years. I am in the process of working with the Town to re-install a leaching catch basin in the front parking lot that was removed in 1997 along with regrading and paving the front parking lot. That should correct any drainage problems in the front parking lot. I may also install a trench drain in floor across the overhead door in each of the smaller units and a tight tank to allow vehicles to be stored in the units. I also want to replace all the fiberglass panels in the building with steel panels with windows, install more insulation, fix the gutters, and replace all the doors. Last fall I recoated the roof. There are no leaks. I may also install cement block along the base of each exterior wall and replace or paint the steel panels. I may install a rear access door in each of the smaller units. Unit F is empty and may be used if the construction interferes with your use of Unit D. • I have restored the water, gas, and electrical services to the building. The gas piping and the wiring were inspected, as required by the Town of Yarmouth, Eversource, and National Grid. There is a relatively new gas unit heater with a wall-mounted thermostat hanging from the ceiling in the bay area of Unit D. There is an electric baseboard heater in the bathroom. You will need to heat the bathroom to prevent freezing if you 336 Maple Street, Mansfield, MA 02048 (508) 212-3500 Mr. Steve Bobola Rob Warren June 17, 2019 Page 2 of 2 want the water left on during the winter. The water is on at the pit under the sink in the bathroom. There are separate meters for gas and electric. I pay for the water. You will need to call Eversource at (800) 340-9822 to transfer the electric account. I would wait until the fall to call National Grid at (800) 732-3400 to open a new gas account. There is a monthly charge of approximately $10.36 to have the gas on even if you do not use any gas. There is a small loft above a work area at the rear of Unit D. There is also a long work bench along the eastern common wall. Brad may leave some wall cabinets in the unit for your use. Anything that is in your way can be moved to Unit F in case someone else wants to use it. Please gain my approval prior to making any other repairs, alterations or improvements. The rent is $800 per month for Unit D. I require the first and last month's rent along with a security deposit of$800. If you want me to hold the unit for you for occupancy on July 1st, please mail me a check for $2,400 check, payable to Pleasant Acres, LLC, to cover the first month's rent ($800), the last month's rent ($800), and a security deposit ($800). I will have the padlock and deadbolt rekeyed once Brad is out and give you two keys. Brad has copies of everyone's key in case of an emergency or if there is a need to gain access to a unit. I will probably give all the keys to Todd because he is there all day if that is okay with you. I will give you prior notice if I need to access Unit D to make repairs. The contact information for the other tenants in the building is as follows: Unit A is Gary Garabrant a boat mechanic at 774-268-0084; Unit B is Todd Hnis a fiberglass guy at 508-344-2522; Unit C is Anthony Franze 617-803-6872 and David Richards 508-965-3823 a couple carpenters; and Unit E is Steve Cole at 774-313-0163. Frank is there making cabinets most days. Everyone tries to help each other. Please call me if you have any questions or comments. Again, welcome to White's Path! Yours truly, "../K4,64.X Ralph P. Penney, Manager SANDD-2 - OP ID: DS •A. R� CERTIFICATE OF LIABILITY INSURANCE DATE $ ) 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 508-775-6060 ?Rem. Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-775-6060 IFAX 508-790-1414 88 Falmouth Road (NC ,N��o,EXt): (A/C,No): Hyannis,MA 02601 ADOREss: Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIC# INISIIIIPO INSURER A:Mapfre Insurance 34754 llar Cust ms LLC INSURER B:Associated Employers Insurance es Path G INSURER C: outh Yarmouth, A 02664 INSURER D: • INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYY1 IMM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY FIN-f LOC PRODUCTS-COMP/OP AGG $ OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BHMWLT 02/02/2018 02/02/2019 BODILY INJURY(Per person) $ 100,000 AUTOS ONLY WNED X AUTOSSULEEDp BODILY INJURY(Per accident) $ 300,000 X HIREDT ONLY X NON-OWNED ONLY PPerr l aR'dent)AMAGE $ 250,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _. EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION STATUTEPER EOTH AND EMPLOYERS'LIABILITY WCC50050197212018 12/04/2018 12/04/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBEER EXCLUDED? T N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Certificate issued for insurance verification. CERTIFICATE HOLDER CANCELLATION COMMUNT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Community Development ACCORDANCE WITH THE POLICY PROVISIONS. Partnership 3 Main St. Mercantile AUTHORIZED REPRESENTATIVE Eastham,MA 02642 Bryden&Sullivan Insurance ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MGL AND FIRE TOWN OF YARMOUTH .:.: REVIEWED FOR CODE COMPLIANCE. ,,,,�t 4 ERRORS OR OMMISSIONS DO NOT RELIEVE THE APPLICANT FROM THE RESPONSIBILITY OF "AS BUILT" COMPLIANCE. DATE:_ -i ' Q fcvp-r. t 0 c-e /L INSPECTOR YARMOUTH FIRE PREVENTION New Business Transmittal Project Name: Sand Dollar Customs Address: 389 Whites Path Unit D Contact Name: Walter Warren Jr. Phone: 508-694-5618 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: 07-17-2019 Copy for Applicant 0 Copy to Building Department Copy to Fire Prevention Entered in Firehouse El Final Inspection t:Yi TOWN OF YARMOUTH Nor HEALTH DEPARTMENT • :�•.` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: 0 //_ � l BuildingSite Location: ? 0/`( i(e-s Pct /`�/"G4 i/✓i 7 Proposed Improvement: 5 Yi' V e 61✓'per v e✓71- a- i 4/ryr 7&/✓S C(.►/(J f 5r'..(c,/ Applicant: (',L4 (40/' L 6f/cf/r A? Tel. No.:5?►- i ' 5 /e Address: o,23 l)6'/s i? /-6 6-,:). c' 6 ya/Malt4Date Filed: 7//0.. **If you would like e-mail notification of sign off please provide e-mail address: Owner Name: /2O fp6 A 41:4 7 Owner Address: 33 6 M4 /' 5141 ed 0/1 d/4' wner Tel. No.: �5 O6 - ,' 2- �� 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: GJ/7Q C_ ocAtod,cfn,c972 DATE: -7 ` I•"7./9 PLEASE NOTE COMMENTS/CONDITIONS: kie3 1-6)ac c 1-4'7 -r-c/Qus (y -rciS S.-t e. 5--1" cse t s -Far R ar-d 56fcrd s .-N /y l • . •off,i,�R� TOWN OF YARMOUTH BUILDING DEPARTMENT • APPLICATION FOR DETERMINATION OF NON-APPLICABILITY • rig C 1°,,� t ��� AQUIFER PROTECTION BYLAW 06.5.1.1 Applicant/Business Name jCcn2( a IA r 4/5kYl5 ZLC Date: 7////// Property Owner: A/,S? / - /p Property location: .N. 71 0 3,?9 G(lii/14/1nit# Map&Lot# Z. Proposed Use:5/i4,Q 7'r7/5 L f0.v,M P'4/ h)J f h ‹<j/ (-4 o 4 I. Has applicant has fully complied with the Submittal Requirements of§406.5.2 ? (Attach copy of Hazardous Materials List) 2. Does the proposed use meet all of the Design and Operation requirements of§406.5.7, 3. Are the chemicals, pesticides, fuels and other potentially toxic or hazardous materials used or stored at the site,or produced by the proposed use, in qualities not greater than those commonly associated with normal household use, 4. Does the proposed use meet all of the objectives and water quality criteria of the bylaw: The above applicant hereby acknowledges that the Building Inspector may require the applicant to submit the matter to the Health Agent or Board of Health,and may require the applicant to demonstrate that he/she has received a favorable report from the Health Agent or Board of Health. The Determination,if made,shall apply only to the individual applicant and proposed use and shall automatically expire upon any change of use or transfer of ownership of the business. There shall be no appeal from an unfavorable Determination of any such application,nor from a failure to act,except for filing by the applicant for a Special Permit from the Board of Appeals as otherwise provided herein. ((.1- 7/6� Applic. ij Date g. -7/0 Print Name DETERMINATION: The Building Inspector, based upon a review of this application and information supplied by the Applicant,hereby determines that the proposed use satisfies the requirements of§406.5.1.I and that the Applicant need not apply for a Special Permit under§406.5 Building Inspector Date Health Agent Date Form must be filed with the Town Clerk and copies of this form must be sent to the following departments(as listed in§406.5.4); Water,Engineering,Fire,Health,Planning,Conservation,Board of Appeals. Aquifer Protection District Waiver 05/08 TO: Commercial Applicants in the APD r` JF 4 • 't• FROM: Yarmouth Health Department SUBJECT: Hazardous Materials As part of the application process for a Board of Appeals hearing or Determination of Non-Applicability, please complete this form and return it with your application. For Rirther information concerning hazardous materials regulations,contact the Health Department Office. In the conduct of your present and/or proposed business, do you store, use, generate any of the following types of products? Please check all which apply and list quantifies Antifreeze, Engine& Radiator Flushes q ) Motor Oil Al(/ d " Hydraulic, Brake,Automatic Trans. Fluid J Gasoline/Fuels 1 Grease,Lubricants Degreaser/Cleaners Floor/Driveway Degreaser Battery Acid R oOfing/ jndercoating Vehicle Detergents Vehicle Waxes,Polishes Asphalt,Tar, Sealers Paint, Varnishes, Stains, Dyes, Thinners Wood Preservatives Dry Cleaning Solvents,Carbon Tetrachloride Floor/Furniture Strippers Other Cleaning Solvents Rock salt,Road salt Drain,Toilet, Cesspool Cleaners Refrigerants Bug&Tar Removers Photo chemicals Printing Inks&Dyes Pool Chlorine Pesticides, Insecticides, Herbicides Rodenticide, Fungicides Nitrate Fertilizer Jewelry Cleaner Leather Dyes PCB=s V Electroplating Sludges -N-V\ Others (List) N Applicant Date: s HEALTAPDDETER 10-99 t . r v l 1 - -'la. a Nd � . ' 1,0AA s, 4-a-0 • • • ' ' ,_,- ::,.I.: COPY 5\ ra()-e. TOWN OF `'; F,f Q cj T E.1 FEVIEWED FOR BUILDING A )2CVLNG CODE CCMPL!- V /NCE. ERRORS OR OMMi.5Sl ,NS DO NOT RELIEVE U APPLICANT FROM THE RESPONSIBILITY OF "AS BUT T" ---- COMPLIANCE. DATE: --3/77 Jo 4,So S�,rc,G� 1 BUILD,i.G C, FICA gt,. „ s�r� � -Y �.d • ch 6-101",ec. 1' • j - v Divil... D 3s-q wkA--e, ki)c-t-AA sc, ar od-u