HomeMy WebLinkAboutBd-20-003551 3cv - as • ID3 SS-4/
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Town of Yarmouth Building Department
1146 Route 28, South Yarmouth, MA U2664 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
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Name of Business � �5 �� c + I�s�Orn ± f-f--&dsl,�
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Property Address �� �1 i �P3 � 1 Unit# C
Type of Business -P\ica\orAeN
*Square Footage to be occupied '3 0 *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
le(5 44 - ) k-eS L L. C
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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 15- 2.. Proposed Use Change of Use: Yes No
Allowed Use: Yes X No APD Waiver: Yes No N/A
B i di g Officials Signature Date •
—_ — •
The Commonwealth of Massachusetts
� L Department of Industrial Accidents
•
_, 1 Congress Street,Suite 100
• _'���`= Boston,MA 02114-2017
.�, • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: B ilders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
� Please Print Legibly
Name (Business/Organization/Individual):` `l 51 1 v\
Address: k )i,lo C
City/State/Zip: r mo p"1\\ y Phone#: a 5 a 7 3 6,9
Are you an employer? eck the appropriate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time).*
2. 7�I am a sole proprietor or partnership and have no employees working for me in 8. ❑Newm Remoconsdeling
any capacity.[No workers'comp.insurance required.] $• ❑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.t 13. Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14•a 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
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:
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 der ains and penalties of perjury that the information provided above is true and correct.
Signature: % {
Date: I/)•la J1
Phone#: a3-)
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�,,YgR TOWN OF YARMOUTH BUILDING DEPARTMENT
( � 2 4 APPLICATION FOR DETERMINATION OF NON-APPLICABILITY
C
O1 1„ 7,/2' AQUIFER PROTECTION BYLAW §406.5.1.1
Applicant/Business Name:k)VS\ vl (4 Date: tt a�l °�
Ira ev., F Ae� a /
Property Owner: � S I 5 L L C � 11 Li 1-0 y, g t
Property location: 3 '\ L)L; 5 t\-‘ Unit# Map&Lot#
Proposed Use: c\-o Ca-Cp
1. Has applicant has fully complied with the Submittal Requirements of§406.5.2 ?Ur"/
(Attach copy of Hazardous Materials List)
2. Does the proposed use meet all of the Design and Operation requirements of§406.5.7, U
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, V
4. Does the proposed use meet all of the objectives and water quality criteria of the bylawV'
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 ap licant for a Special Permit from the Board of
Appeals as otherwise provided herein.
10\i!‘11•1
Applicant Da
k16'- ‘ v1 lion
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
Gik°411414R1/ . I�-9/�
Building Inspector Date Health Agent Date
Form must be tiled 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
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TO: Commercial Applicants in the APD
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 further 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? Place 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
Rustproofing/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: !4a f r ct
HEALTAPDDETER 10-99
r Li t)
L 1 ! l'
YARMOUTH FIRE PREVENTION
New Business Transmittal
Project Name: Justin Hogg Plumbing Address: 389 Whites Path Unit C
Contact Name: Justin Hogg Phone: 508-237-3694
IY N NA Subject Regulation
ES 0
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.
* YFD permit required-depending on occupancy and submittal
*Per 780 CMR 901.5, contact Yarmouth Fire Department for acceptance test.
*Per 527 CMR 1 13.1.8, a permit is required from the Fire Department to shut down any
fire protection system.
Sprinkler system review with building Department
* YFD permit required-depending on occupancy and submittal
Plan Reviewed By: Captain Kevin Huck Date: 12-18-2019
Copy for Applicant 0 Copy to Building Department Copy to Fire Prevention
Entered in Firehouse n Final Inspection
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TOWN OF YARMOUTH RECEIVa
r HEALTH DEPARTMENT DEC 'I 8 2 19
PERMIT APPLICATION SIGN OFF TRANSMITTAL SH a.E1HEALTH DEPT.
To he completed by Applicant..
Buildin Site Location: 3 F°C U h i-tP S fo.j ` 0 fi
Proposed Improvement: Sip rote O W )cr- / &c, {-1`„-,ckr d i t4 Lc\N, I
Applicant: J Tel. No.: S(n a 3") 3 61(.4
Address: 63 reol Date Filed:f a _
**If you would like e-mail notification of sign off,please provide e-mail address: \ L J,M 1✓l nv, CG✓i'N
Owner Name: 6-c-f`P 5 C._. C Oek •
Owner Address: 33c, Or L SI- OlcfN5 Owner Tel. No.: 5O ��3,- 3 5'00
oao-1
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: __C �cgri. DATE: I Z&-/9
PLEASE NOTE
CO ENTS/CONDITION. :
6 Gn-7 1v G 2�-, i'iLs