The URL can be used to link to this page

Home My WebLink AboutBLD-23-004686 I • , .` .• of -eit,t BUILDING PERMIT APPLICATION • . • . .c '$- APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, G OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. t- K.r,. =� ,T Town of Yarmouth Building Department g ( 146 Route 28 • Yarmouth, MA 026644492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 gc1�a3 DtFve U y Planning Boat Information Assessors Department Inlontsatinn: Permit No. v Date tan Type. Map Permit Fee $ /'//b� (,t) Endorsement Date / l�Vb Reoording Date New Deposit Rec'd. $ Date Plan No._ l.-0 Propel DimersifFEETIV1 ET Net Due $ Other_ Lot Area(sf) Lot Qovelgpe This Section for Office Use Only FEB .e3 1U23 , Building Permit Number Date Issued: - -- Signature: O- 3-o1.. I Certifiatetaflecuparicy-- Building Official Date I is is not required 1 Section 1 - Site Information 1 1.1 PProperty Address: 1 1.2 Zoning Information_ (7 ` 9 cd h i�e I?( IC S r Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required I Provided Required I Provided I 1.4 Water Supply(IS-Q.L..c.40.S 54) 1.5 Flood Zone information: Continents Public Private Zone: BFE i Section 2 - Property Ownership/Authorized Agent 2.1 Owner of Records S(-A-0, " ) Q van•Q_AA _ L__ Z 0 L;v\n,o._1 \ l n• Lilk fv „1A-- of( Namq.6rint - ) Mailing Address: Signal Telephone Telephone Email Address: J 2.2 Authorized Agent Harm (print) 7 �{ C� Mailing Address: /� I 7,e,-/��( 77(1 G/Z /Z4/2 9A4 Crt✓ '4YI h'7 ct Q lM.t,_., Signature Telephone Fax Emal Address'. j c Section 3 - Construction Services 3.1 Lice pied Construction Supervisor: Not Applicable ID L \NUeC W1� c L.\ U hJYt rU, �,A W �U fWI(9 �1,�v� . U�a-i License Number Address _-- / c Date -, // 7 J C.1 3 -7 d Erpiration� 7`�Z�Z�Z v U �[�t�'�1 LlArieu✓i r y 7 � Signature Telephone Email Address:cc cQ 4 /0 Z3 z (. . • 3.2 Registered Home Improvement Contractor. Company Hama Not Applicable ❑ C • C/Ovv� (�� r\\ ( ��J � // Registration Number Cv S 1/ v c,f UK tad e- L{mil . Al . 6l u+'tx-"c Uc/ At4 Espt:r!kon Date Signature � Telephone -1-� Z / z L/z e U `-(/Z) Section 4-Workers'Compensation Insurance Affidavit (M.G.L c. 152 S 25C(6) 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 . No Section 5- Professional Design and Construction Services-for Buildings and Structures Subject 1 to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Architect Not Appliable 'J 1 Hama (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineers) Hams Area of Resporsbility Address Registration Number Signature Telephone Expiration Date Hama Area of Respons uTity Address Registration Number Signature Telephone Expiration Date Hama Area of Responsibilty Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor C c-r fc 4 Not Applicable ❑ Company Hams / �/ /t t iECAA7i U Person Responsible for Construction //,�� UU l/ l/✓LVI)� L Y ✓1 , Get `LU r1Zc Wl/ GLf 6r (/Z 613 Address 77 / 2/ Z q2g Signatt /�� Telephone . • , Section 6 - Description of Proposed Work(check all applicable) " New Construction J 1 (tor multiple family only) No. of Bedrooms (for multiple family only) No. of BathroOrnS Existing Bldg. ❑ j Repair(s) ❑ Alterations ❑ Addition (21 Accessory Bldg. ❑ Type 'Demolition Other Specify: I _ Brief Description of Proposed Work: q ►fin V'c.)0 Section 7- Use Group and Construction Type _ Building Use Group (Check as applicapable) Construction Type - A ASSEMBLY ❑ A-1 rJ A-2 0 A-3 ❑ IA 0 A-4 ❑ A-5 Q is J B BUSINESS I ❑ 2A ❑ E EDUCATIONAL 0 2s F FACTORY 0 F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTTTU71ONAL ❑ I-1 ❑ 1-2 i❑ 1.3 0 33 ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL O R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S STORAGE (❑ s-.1 ❑ S-2 ❑ 53 ❑ U UTTL(TY 3 SPECIFY LS MIXED USE ❑ SPECIFY S SPECIAL USE ❑ SPECIFY Complete this section if existing building undergoing renovations,additions and/or change in use.I Existing Use Group: Proposed Use Group: Existing Hazard Index 7B0 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area Building Area Existing(if applicable) Proposed Number of floors or stories i include basement levels j Floor Area per Roar(st) Total Area All Floors (sf) Total Height (ft) 1 Section 9 - STRUCTURAL PEER REVIEW (7B0CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No 1 SECTION 1 Oa OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 0 J E S% iv , as Owner of the subject property, hereby autl ztc----\ 1.d n 44a.cck/i_i e) to act on my behalf,'in all matters relative to'work authorized by this building permit application. Z z 5 Signature of Q r I ID SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION I, 3i., 12U/(41\SiA- as Owner/Authorized 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 arid)penalties of perjury. Print i Signature of Ownlr/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by pernit applicant 1.Building vvi✓} 2 Electrical 3.Plumbing/Gas Z C)U U 4.McCtar ical(F{VAC) 5.Fire Protection 6.Total=(t +2+3+4+5) 7.Total Square Ft.(krnew senctais 6:alto* Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) The Commonwealth of Massachusetts �1F Department of Industrial Accidents =�_ 1 Congress Street, Suite 100 _':► - Boston, MA 02114-2017 -v. - 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/Individual): ((c rK C477,eyi Fey 6(iv / 'tc t i ' Address: .-L1 /'GC wife, G✓l_ t4" go rvu-<•v(vI rr tcl , City/State/Zip: Q.hsA 4.yv.4wd4/ oZ‹..7 Phone #: 77(/ - Zl Z - `/ZI1O Are you an employer? Check the appropriate box: Type of project (required): l.D I a a employer with employees(fill]and/or part-time).' 7. _ New construction 3 1 am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity. [No workers'comp. insurance required.) 3., I am a homeowner doing all work myself ,t 9. ❑ Demolition } [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on mY PP�•n ro < Y• 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.❑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.D 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#i 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. ZContractors 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 ant 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: I Job Site Address: let ( ,t-•� {'GLk, h I o Oc�5 City/State/Zip: ,,,,,,,„14,41,s4- tV,c.,_. U Zos- 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 2�2z/$ Phone#: 77cf- Z/z - qzjU 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#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 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. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at �( �—.� �,�,�� to Work Address Is to be disposed of oat the following location: Lv'&uijc . kiJV\&-\0 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 2z '' Z 23 attire or Application Date Permit No. r ° ..._ 4i,,V TOWN OF YARMOUTH BUILDING DEPARTMENT `Y Certificate of Occupancy .:A1i z wArrA a.* b1 In accordance with The Commonwealth of Massachusetts Building Code Per it No. Location 7 AZcyrzyti ( , ) a 7 Type of Building Has been inspected and occupancy is approved. Date --**:,/,'",&......5Building commissioner This certificate must be posted in a co icuous place. - I 1 .,r,� ....44...:+.m.._4rvti.c.... e.0 Itrt...::� u'a..�',...• '+•• .w.�..vn l� .�,1W.vusi5.�3.a.:�' " ,i�.�..w..�1:MJ0i l..'.it a.�i' N.u'.+..wi..�u.iYa.:tiLui.B�a d.�.a.rw�au..+v Ls.:ti...:uW1..�k.<n... s •. u.—y.� nY.rY...w�uw� ua..)wwa....a. • } Q TOWN OF YARMOUTH BUILDING DEPARTMENT e A. fe ' C i Certificate of Occupancy h. 2 1..z NATTAC ME / $# ,/ In accordance with The Commonwealth of Massachusetts Building Code --,..,:;•-,:*.i;.1='-••"' Peraiit No. Location ---,.. 1--C1/4576.- Type of Building Has been inspected and occupancy is approved. , „ ----V Date 6.- /‘ C)' --3 Building Commissioner This certificate must be posted in a conspicuous place. L.-- - ''''4 -- 41-4'..--- .7--------- „ . ..*