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Home My WebLink AboutBld-20-003550 Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,.M # 02664 tel. 508-398-2231 ext.1261 Use and Occupancy Permit Application In accordance with the provisions of the Massachusetts State Building Code, section 105.1 Application for a certificate of use and occupancy permit Name of Business 7A/r I1bM42(/` Property Address 3 Ty la?/ ,/-4, Unit# C Type of Business /9kApy A,I y *Square Footage to be occupied frC) *attach floor plan Fee: $60 The applicant is required to obtain approval sign-offs from the following departments as checked off below: X Health Department— 508-398-2231 ext. 1241 X Fire Department— Fire Prevention, 96 Old Main Street, 508-398-2212 Other 0' -!4 s 4+i e Y.!f L L C Building owners Signature Applicant Signature Please note: this permit is for use and occupancy only. Any work requiring a building permit will require a licensed contractor to submit an additional application with all the required information based on the scope of the project. **Office use only** Zoning District 6 Proposed Use Change of Use: Yes No Allowed Use: Yes 2( No APD Waiver: Yes No N/A Building Officials Signature Date _ _ . The Commonwealth of Massachusetts • t�=' ►�_ L Department oflndustrialAccidents f' • i~ =170P= • 1 Congress Street,Suite 100 04%--i) f= 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 Name (Business/Organization/IndividuaI): i) A' Address: City/State/Zip: 1. iit c5 Phone#: .e r CO -3/7S Are you an employer?Check the appropriate box: 1. I am a employer with Type of project(required): ❑ employees(full and/or part-time).* 2 '1 I am a sole proprietor or partnership and have no employees working for me in 7. 0 New Jelin construction . y capacity.[No workers'comp.insurance required.] 8. ❑ Remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 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 proprietors with no employees. 11.0 Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.* 1' Roof repairs 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 I.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck *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: 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sgnature: Date: /0//I Phone#: )r ) ' 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#: o \\ 1-1-11 i-- tot - ri O N." p 1j`+t I 1 ,cw .R [ r .-s- •oirA TOWN OF YARMOUTH BUILDING DEPARTMENT • .y APPLICATION FOR DETERMINATION OF NON-APPLICABILITY O1� )c)c 1„�,../s AQUIFER PROTECTION BYLAW §406.5.1.1 Applicant/Business Name: , y,- ,t1 Date: /? L it Property Owner: X17,10 A/le_ / l{R s e K 1 II cr it $ L t C Property location: 3 `i�'p/ / $ A. Unit# Map&Lot# Proposed Use: c 'ee 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, 1( 4. Does the proposed use meet all of the objectives and water quality criteria of the bylaw: X 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 ofany 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. l e l Applicant D to tee t i 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§406.5.1.1 and that the Applicant need not apply for a Special Permit under§406.5 Cceja&knA ! 2—L9 —0 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 ti • J` • t FROM: Yarmouth Health Department � f I • SUBJECT: Hazardous Materials As part of the application process for a Board of Appeals hearing or Determination of Non-Applicability, plea complete this form and return it with your application. For thither 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 quantities. Antifreeze, Engine& Radiator Flushes Motor Oil Hydraulic, Brake,Automatic Trans. Fluid Gasoline/Fuels Grease,Lubricants Degreaser/Cleaners Floor/Driveway Degreaser Battery Acid Rustproofrng/Undercoating 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 Electroplating Sludges Others (List) Applicant Signature: Date: /&/l//y' HEAL TAPDDETER I 0-99 RECEIVED - TOWN j~,t OF YARMOUTH !AC 18 Y019 o , 46.° HEALTH DEPARTMENT 1, HEALTH DEPT. PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: f Building Site Location: j W`�� f e 5 c)--cl 1 ja Proposed Improvement: Sc4o CS6u o C • Hit` u e / tIV D i\L"-.)Af'd ok.S /''1 drr,� Applicant: 4Le11c) re,(Y,,zA Lo Y Tel. No.: 'O 360 %1)5 Address: Li 11,✓-e(`Qk\ 50,) A 5 4114 oa660 Date Filed: IV\ **If you would like e-mail notification of sign o ,please provide e-mail address: Owner Name: pc,,Ift, fct '/ P\ecS-shc ��iNe5 L�,G Owner Address: 336 /Yl.l J�' IV A,nfe(c) 'VV4 l 0)0(1$ Owner Tel. No.:603 al-a 3se,T) 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: CP4 A DATE: /2-19— 9 PLEASE NOTE CO MENTS/CONDO S: / / , D2p7`. pricy- 0 2 01C any —fGxfc GE" I1G2.rct`aG5 /. .