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Home My WebLink AboutBLD-23-001832 , • --01 *Y.9,Q BUILDING PERMIT APPLICATION • . 4�CF • \Zr� APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, oG� _ I:% _\c OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY D Town uI larmouth Building Department M�TT�C P.CCS r. t t %) 14^..- *,@'• 1146 Route _'3 • Yarmouth, MA 02664-4492 Tel: 508-398-2231 ext. 1261 Fax 508-398-08 36 OCT 0 4 2022 Office Use Only Planning Board Information Assessors Department Information BUILDING DEPARTMENT Permito��3-b()l3�ate Plan Type Map �Y Permit Fee $ GU,06 Endorsement Date / Recording [late New Deposit Rec'd. $ (pO�ate F`3i• i(il Plan No._ 1•4 Property Dimensions: lir— Net Due $ Other_ Lot Area(sf) Frontage(ft) Lot Coverage This Section for Office Use Only Building Permit Number. Date Issued: Signature: 10- 3. Certificate of Occupancy Building vial Date is Is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: t/ 13 ) d $ f S O U \lanYLek 1 i\ti\ 01-lO(CLi Zoning District Proposed sed Use 1.3 Building Setbacks(ft) - Front Yard Side Yards Rear_ Yard Required Provided Required I Provided Required Provided 1.4 Water Supply(M.a.l,,,c,40.S 54) 1.5 Rood Zone information: Comments Public Private Zone: BFE Section 2 - Property Ownership/Authorized Agent 2.1 Owner of Record: 14 OmGS r�� 1 (��; �_ 3,5 Monroe \ Q, \fr Ml / N n Mailing Address: 0 (o 3 Signature Telephone Telephone Email Address: 1 2.2 Authorized Agent 1 ic t N) Ipb v 1 cJ 3'3 - . rnou11 LSt . 11)0_6 Name fprint) 1 Mailing Address: (cKA_-1_ - t..� I0g-3(00- 31L1 1 \k)W • Ai a 631 Signature Telephone Fax + m/ail F�ddress: Section 3 - Construction Services �U 1 p��vv�' �' ''�l ��` " vLA 3.1 LlcensLtl Construction Supervisor Not Applicable i] %ic fs►`n Y o V A Cv\ _tU Q e RD Gut' t• Lovt Skiu'k_et i c`c) C.S. I i 4)1I :50 / O (09- License Number Ad.r .S .� l a -, -a: !► • 5OS 3 GO 3` Li ( Expiration Date Signature p Telephone Email Address: • • ' )OPOv:ca, k..LA,v)' y Of) t c... _ • . ' r• r 3.2 Registered Home Improvement Contractor. , r - .'s. Company Name Not Applicable ❑ Registration Number E Address E xpi2tion Date Signature Telephone 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 j . 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) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name • 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 , Not Applicable ❑ Company Name Person Responsible for Construction Address Signature Telephone Section 6 - Description of Proposed Work (check all applicable) • New Construction ❑ (for multiple family only) No. of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ❑ I Repair(s) U Alterations ❑J Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: l Brief Description f Proposed Work: RCLVICLUA_ e'llr\ cA 0--Q_C___ il-A, Lf21\PtA. ( eLA-Pi Section 7- Use Group and Construction Type I Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A-4 ❑ A-5 ❑ 1 B ❑ B BUSINESS ❑ za 0 — E EDUCATIONAL ❑ zB ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ 1 I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ I-3 ❑ 3B ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S STORAGE ❑ S-1 ❑ S-2 ❑ 58 ❑ U UTILITY ❑ - SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this section if existing building undergoing renovations; additions and/or change in use. Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 78D CMR 34 Section 8 Building Height and Area • Building Area Existing(if applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height (ft) Section 9 - STRUCTURAL PEER REVIEW (7B0CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER' ENT CONTRACTOR APPLIES FOR BUILDING PERMIT I,�� 4. � , as Owner of the subject property, hereby autho ' ��YN1fa \)1 C to act on Imy behalf, in all m ers r tive to work authorized by this building permit application. 5� ature of Ow Date r , SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION ' • I, .'vY) FeD iv)U\ Lc \ as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acute, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Ki-,,,, Popo vk co-, . Print Na , ......ic me k r "L-t z: L.; 1 01 LIOa Signature of Owner/gent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building • 3Aw< 0 a Electncal 3.Plumbing/Gas 4. Mechanical(I{VAC) 5.Fire Protection 6.Total=(1 +2+3+4+5) 3,00,0c) 7.Total Square FL(ta nem smc4�n a aDdbxe) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical - Commission approval (if applicable) ,, .r i The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 ti f Boston, MA 02114-2017 �r�, v�,, www.mass.aov/dia `� «Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): N(Dal G.np (? 4 , t K Address: 3.33, m aun% S\---.. \IN,1b l 0 240- -0 r City/State/Zip: Phone #: s-0'- 1(0 V-3(Lt i Are you an employer? Check the appropriate boz: Type of project (required): l.❑I am a employer with employees(full and/or part-time).* — 7. Ell New construction 2 1 am a sole proprietor or partnership and have no employees working for me in ca aci 8. ❑ Remodeling an y p ty. [No workers'comp. insurance required.] 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 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions pro 12.❑Plumbing repairs or additions rietors with no employees. 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.t 1 '•❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other dQ_C 12.12ibcuLo 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. t 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 nu„gmployees. Be ow is the policy and job site information. !l Insurance Company Name: �e�,��,(��,,M�� ‘ c p y j ` " ' `L S I L/y . -LiA USG i CIIlifinClA i Sht,p Policy or Self-ins. Lic. #: J vaL 5OO-501 ` bi10I-doll A Expiration Date: la-a,'), - Job Site Address: \ 5' J C . City/State/Zip:c. NCLA.Prni3u 4- PM 02j,Qlc Attach a copy of the workers' compensati4n policy declaration page(showing the policy number and expiration date). I 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. I do hereby cert.y under e pains and penalties of perjury that the information provided above is true and correct. iSignature: 6,44,,..A._ Date: /OJS/off 3- Phone#: 508"- , D 0 3 (q 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 whb 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 §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 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 I -Id brvacsz,gared S.4OmXh ,L1i4 02s4 Work Address Is to be disposed of oat the following location: `I OJJY \ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. 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