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HomeMy WebLinkAboutBLD-23-003858 , i; . ' c` 1VE I r - I RBUILDING PERMIT APPLICATION �� 1,y '�*o APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, ' J 0 l� • [ OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. t_---__-_-- _ -, .T: Town of'lamiouth Building Departrnrnt BUILDING DEPA• 11-ifi Route 28 • Yarmouth, MA 096544499 eY — - .a' Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 >J Office �2 ice��e Onto_ Planning Board Information Assessors Department Information: Permit N4. v,'v Date Pan Type Map lot Permit Fee '' ' Endorsement Date 32 / 91 Recording Date New Deposit Rec d. $ Date 1.4 Property Dimensions: Plan No. Net Due $ Other 40,009+/- 189.99 Lot Area(si) Frontage(ft) Lot Coverage This Section for Office Use Only Building Permit Number / Date Issued: Signature: .,,r ;% — `3 i Certificate of Occupancy // -_ Building Official • Data I is Is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning information: 668 Route 28 West Yarmouth, MA r II B-2 No change/Business Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard ! Side Yards I Rear Yard Required Provided I Required 1 Provided Required Provided 30 33 25 15.2 20 11.7 1.4 Water Supply WALL-c.40.S 54) 1.5 Flood Zone information: Comments Public Private Zone: AE BFE: 11 Section 2 - Property Ownership/Authorized Agent i 2.1 Owner of Record: Gerry Manning,Trustee-The Parker River Realty Trust 121 Mayflower Terr So Yarmouth,MA 02664 Name(y1,0) -yjci....,L Mailing Address: ."� 508-364-8700 gerrymanning@comcast.net Signature - Telephone Telephone Email / Address: 2.2 Authorized Agent I • George Moudouris, M udouris Construction,Inc 12 Athens Way West Yarmouth, MA 02673 Nary*(print) Mailing Address: ( Y; c w 1—f 508-778-4586 MoudourisConstruction@gmail.com I Signature Telephone Fax Email Address: Section 3 - Construction Services 3.1 Licensed Construction Supervisor Not Applicable George Moudouris, Moudouris Construction,Inc 12 Athens Wa W st Yarmouth, MA 02673 License Number A ess CS-066290 MoudourisConstruction@gmail.com OS 778 4586 Expiration Date nature Telephone Email Address: 07/12/2023 • 3.2 Registered Home Improvement Contractor: Company Name Not Applicable ❑ • Moudouris Construction, Inc Adfs / 12 Athens Way W Yarmouth, MA 02673 Registration Number . �� 5A8r 7 t586 139811 -b ` Ext.i ration Date Signature Telephone 08/24/2023 • Section 4- Workers'Compensation Insurance Affidavit(M.G.L c. 152 S 25C(6) 1 Workers Compensation 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 ...X No Section 5- Professional 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 Registered Architect Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s) Hame Area at Responsibility Ad Registration Number Signature Telephone Expiration Date Name Area at Responsibility Address Registration Number Signature Telephone Expiration Date Hams Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor LI Moudouris Construction, Inc Not Applicable Company Ham. George Moudouris Person Responsible for Construction 12 Athens Way W t Yarmouth, MA 02673 Address 508-889-7794/508 778-4586 Signature Telephone • ' • ' ; . Section 6 - Description of Proposed Work(check ail applicable)I New Construction 0 I (tor multiple family only) No.4t Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. Repair(s) G Alterations 1 � G Addition ❑ Accessory Bldg. ❑ Type Demolition I Other Specify: P fY: I Brief Description of Proposed Work: INSTALL 2 NEW WINDOWS AT FRONT CORNER OF BUILDING. ARD IN EXISTING BATHROOMS. !Section 7- Use Group and Construction Type J Building Use Group(Check as appficapable) Construction Type A ASSEMBLY 0 A-1 ❑ A-2 ❑ A-3 ❑ El A-4 ❑ A-5 ❑ 1 B ❑ B BUSINESS j ® ❑ 2A E EDUCATIONAL ❑ ❑ F FACTORY (' F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD (❑ 3A ❑ I INSTITUTIONAL i ❑ I-1 ❑ 1-2 ❑ I-3 ❑ 3B ❑ M MERCHANTILE I ❑ BRESIDENTIAL ❑ R-1 (3 R-2 0 R 3 ( ' SA ❑ S STORAGE ❑ S1 Ca SPECIFY* S--2 ❑ 59 cl U UTILITY SPECIFY: - M MIXED USE ❑ SPECIFY: _ S SPECIAL USE D SPECIFY_ _ Complete this section if existing building undergoing renovations;additions and/or change in use.1 Existing Use Group: B Proposed Use Group: B Existing HP-ard Index 7BD CMR 34 Proposed Hazard Index 7BD CMR 34 Section 8 Building Height and Area { • Building Area Existing(i applicable) ' Proposed Number of floors or stories include basement levels Floor Area per Floor(st) Total Area All Floors (sf) Total Height(ft) Section 9 - STRUCTURAL PEER REVIEW (7B0CMR 110 11) f Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Gerry Manning,Trustee-The Parker River Realty Trust , as Owner of the subject property, hereby authorize George Moudouris, Moudouris Construction,lnc to act on my behalf, in all matters relative to work authorized by this building permit application. 01/17/2023 • Signature of owner ; Dale • SECTION 7 Ob OWNER/AUTHORIZED AGENT DECLARATION • George Moudouris, Moudouris Construction, Inc , as EximplAuthorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. George Moudouris, Moudouris Construction, Inc Print Name 01/17/2023 Signature of O /A Date Section 11 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2.Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection 6.Total=(1+2+3+4+5} 4 T.Total Square Ft.Ilor new 11114tall5&a i tixni a't, // Check Below f ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) • §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223t1 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. 44, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 668 Main St tRt 28 West Yarmouth Work Address Is to be disposed of oat the following location: Yarmouth Town Dump Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 1411"6 �f�3d i2 01/17/2023 Signature of Application Date Permit No. The Commonwealth of Massachusetts t, 1; �t Department of IndustrialAccidents . swim- I Congress Street,Suite 100 111 1. — . Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit;Builders/Contractors/Electi-iciansiPltzmbers. TO BE FILED WITH- a,PERMITTING AUTHORITY. APPlicanl.Information _ Please Print Letziblv Name (Business/Organization/Individual): Moudouris Construction, Inc Address: 12 Athens Way City/State/Zip: West Yarmouth, MA 02673 Phone 508-778 4586 Art you an employer?Check the appropriate her: Type of project(required): 13[am a employer with 4 employees(full andktrpart-time)_4 7, 0 New construction 2.❑I am a sole proprietor or pattruarship and have no employees worttng for me in 8. Remodeling any capacity.[No workers'comp. insurance required.) 3. I am a homeowner doingaII work 9. [~], Demolition nryselC l3�}o wot ken S'cutup.insurance requiring t 4.❑I am a homeowner arid w jl be hiring contractors to condtux all worse on 10 ©$uildi0g addition ensure that all contractors either have workrrs' I wr7t proprietors with r o enmiae�ye 'insurance sale 11.0 Electrical repairs or additions 12.❑Plumbing repairs or additions 5.E1 I am a general contracmr and I have hired the sub- actors listed en the gybed sheet. These sub-cost actccs have employees and have workers'oomp.insurance.: 13.0 Roof repairs 6.a We arc a corporation and its officers have mercised their right of ( I4.0 Other . 152,§I(4),and we have no employees.[No workers'comp.is�vronaua; per MGI.c requic,ti.] *Arty 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. tContrecto s that cheek this box must attached an additional sheet showing the name of the sub-oomnictors and state whether or not those entities have employees. If the ors have employees,they react provide their workers'Wrap.policy=mbe. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Tame: Travelers Policy 4 or Self-ins.Lic.# 1Jt3-2E211009 Expiration Date; (� //� tiOZ Job Site Address: 668 Main St(Rt 28) City/State/Zip; W.Yamiouth, MA 02673 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,§2SA 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$250,04 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 under the pains and penntt►vc of perjury that the information provided above is true and correct. Signature: Moudouris Construction,Inc Date: ungggirgiK 01/17/2023 j'bone#: 508-778-4586 Official use only. Do not write in this area,to be complet d by city or sown of rinT } City or Town: Permit/Lieease# 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# Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons-tilt) f l`��f lSiS ry i s a r CS-066290GE Opires:07/12/2023 GEORGE ;:, r, 12 ATHENSM WAY ' , WEST YARMO4JTH MA 02673 <)14h.}{12� Commissioner n if. „con i Office of Consumer Affairs&Business Regulation gu a on HOME IMPROVEMENT CONTRA R TYPE;Corporation istr ti 1 ti.4tt Reg__ � � p�g�j2412023 139811 MOUCOURIS CONSTRUCTION INC GEORGE M.MOUDOURIS 12 ATHENS WAY undersecretary W.YARMOUTH;MA 02673