HomeMy WebLinkAboutBLD-23-003566 • , Viii R\ DEC 2 9 2022
• • . pF•Y-4,4 BUILDING PERMIT APPLICATION t.7ING DEPARTMENT (
APPLICATION TO CONS i ' •-RUCT,REPAIR, RENOVATE, CHANGE THE U = '- • • • �1
.O _G OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Town of-Yarmouth Building Department
/� %.TT" 1146 Route 28
/' `� Yarmouth, MA 02664-4492
�'� Tel: 508-398-2231 ext. 1261 Fax 508-398-0836
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6t—r\ Dffice Use DOnlyPlannin5;Board Information Assessors Department Information:
Permit No. �U oto Date Plan Type• Map Lot
Ll Permit Fee $ ) C Endorsement Date
CO
l Recording Date New
Deposit Rec'd. $ / ate plan No._ 1.4 Property Dimensions:
\I GI\j-'')
Net Due Ci r{A 0 1 ,Ik ther
k (_L'�}i — Lot Area(sf) Frontage(ft) Lot Coverage
i1�C1� C I C)j�(1 'This Section for Office Use Only
�W� Building Permit Numbe Date Issued:
Signature: �-' i� ` e _ 1� Certificate of Occupancy
Building al ' Date0 is I,not n3qulred
Section 1 - Site Information I
1.1 Property Address:
�� 1.2 Zoning Information:
O cJ4 I Jf M 0-)k MIA. (\Z- ' Zoning District Proposed 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 Flood Zone Information: Comments
Public 'e'z Private Zone: BFE
Section 2- Property Ownership/Authorized Agent
2.1 Owner of Record;
4 L--:") P. , ✓r,;l<t•Iv--' -701 1/4L(e-.t -+- ( vitivf4,-5 tit/l\
Name(print)-- --- Marling Address
5 0 _ 'C E-G40 4 rC�c�{utcc)
T 1 (i •-U- N5 611---7e i'(- • c.ts.,A-,
Signature Telephone Telephone Email Address: I
2.2 Authorized Agent:1
t1an+)(prim --- t-�, _l c ) i•,k(W ; 1L-'!-tzzA f S-tt/P
—( Mailing Address:
Signature Telephone Fax
Email Address: i
Section 3-Construction Services
3.1 Licensed Construction Supervisor: Not Applicable
r'-)raui;, I nprs, J
1 )A ) IJe,rv.,1 d i i\ 0�(v`J License Number
Add ii rr�� J ]] U' 7-2, 2 Li
P• M /✓t �� 11,-i-E G g.oz,DG "6{'G.Uf.01'1rIG,,C3 cj,_ Expiration Date
Signature •
Telephone Email Address:
/nyhre lo brill) 5
e /,cavi
3.2 Registered Home Improvement Contracto-ri •
Company Name Not Applicable ❑ _ •
r "'
`0I " v )-1rvtcAs Cor' .
Address � � Registration Number
.itx,Date
Signature Telephone C.`_/-i-20Z 5
• 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 1• 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 0
Name(Registrant):
Registration Number
Address
Expiration Dale
Signature Telephone
Section 5.2 Registered Professional Engineers)
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Hama Area of 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
G6 r !L'D 3 e/ u a( j LOT Not Applicable ❑
Company Name /� ,.
Person Responsible for Construc
tion
t f cc S. /).,2Y11; .S/)"1 I O'7/fe,LID
Addy¢ `'/r 41qy Zb�'0L,7 0
Signature Tel phone •
' • : 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. [] Repair(s) I✓ Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type I Demolition Other Specify:
P fY:
I
Brief Description of Proposed Work: �pI
Q1 cb n 0 L-) tI. cui e, i [e r as c -i-�ci "
Section 7- Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
A ASSEMBLY El A-I ❑ A-2 ❑ A•3 ❑ to 0
B BUSINESS CI 2A
❑ A-5 ❑ 1B ❑
2A
E EDUCATIONAL ❑ 2B ❑
F FACTORY
❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD El ,
3A 0
I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ 1-3 O 3B ❑
M MERCHANTfLE ❑ ❑
4
R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S STORAGE
U UTILITY 0 S-1 ❑ S-2 ❑ 59 ❑ .
SPECIFY:
AA MIXED USE ❑
SPECIFY:
S SPECIAL USE I ❑
SPECIFY:
Complete this.section if existing building undergoing renovations;additions and/or change in use.1
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 7B0 CMR 34
Section 8 Building Height and Area 1 •
Building Area Existing(ii 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 (730CMR 110 11)
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, LkL7 O•e G 6.'-or( , as Owner of the subject property,
hereby authorize B 7_„ .1--1U - _att4_) � ' .r, (U , c(,�t
to act on
-
my behalf, in all matters relative to work orized bi this building pen-nit application.
Signature of Owner `----- Data
r
SECTION 1Ob OWNER/AUTHORIZED AGENT DECLARATION
I, A1Q G`' �.qr v^ , 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 and penalties of perjury.
r • .o
Print Name-
_ - lz- Lc — Z 2
Signature of O er/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
a Electrical
3.Plumbing I Gas 2 J U
4.Mechanical(HVAC)
5.Fire Protection
5.Total=(1+2+3+4+5) ry
7.Total Square Ft.awns.,ms sao&aaitiae) j!1 U U
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
J. .„
...
' V' Commnonowl eoacttenu paof tAiii cansasi 2LeihcUeSnastutSre
T' Boardpolvfisal°udding Re ulations and Standards
r, Citirr-54,-.,...
Office of Con,Auraker Affaim Ci SluOtrtoss St-2'413ton
1-00ME IMPROVEIVIENT COAITRAC t OR '---' '
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TYPE: InclAiduat CS-110548 .5 14APires:°512312°24
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Rosi$Arrition Expirptioli BRAuLto eRfro
1,......,,
irf,7C01 02 14'4.'023 19 SAGA ROAD
esAuLto BRiTo SOUTH DENNIS MA 02660
D B.A SSRITO SES-IVICES Pc
BRAULIO BIT° •DENNIS, .,:- rk tf&ncaa-
rarnmissiOrier Ldia . i
19 SAGA RD ' al4sr,:i
SOUTI-i .MA 02660 '
tirlder$ZCreta commisstortiar „..2, ,,a
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. The Commonwealth of Massachusetts
1* �� _ Department of Industrial Accidents
=0Q i
1`�`' I Congress Street,Suite 100
e,� Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPIumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information J Please Print Legibly
Name (Business/Organization/Individual): ((`(kJ i p �✓6' f`1 C 0
Address: l qi Sa,)aC k d
City/State/Zip: 10 r'tnij /1i / 02.66 it Phone#: ?' i-ZE 3 -01.706
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with employees(full and/or part-time).*
7. New construction
3I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.) 8. El Remodeling
3. I am a homeowner doingall work myself. 9. ❑Demolition
❑ ys [No workers'comp.insurance required.]t
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 11.❑ Electrical repairs or additions
proprietors with no employees,
12.❑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.t 13.El Roof repairs
60 We are a corporation end 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 41 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 my employees. Below is the policy and job site
information.
•
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: q- I t AtG✓ �� r�+ ,V1 SI;. $$ City/State/Zip: 5. (kx.v my C k,h
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.
I do hereby certify under the pains nd penalties of perjury that the information provided above is true and correct.
Signature: /_'2 �/{, ��y'�" Date: 2—z Y '� 7
1
Phone#: \I 14—?C OL oil
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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#:
COMMERCIAL ONLY BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: 1 5 K J,r -LScope of Proposed Work: V)��M vxi'+ �� 1 c �Ll✓1 �"�� `�"'�'�� �` �"f A
t1`
Date: k'Z- Z - 2 2
Based on the scope of work described above, the applicant is required to obtain approval sign-
offs from the following departments as checked-of below:
Health Dept.—508-398-2231 ext. 124:1
Conservation—508-398-2231 ext. 1288
Water Dept.—99 Buck Island Road, 508-771-7921
Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292
Engineering Dept.—508-398-2231 ext. 1250
Fire Dept.—Kevin Huck/Scott Smith, 96 Old Main Street, SY
Note: Please call Fire Department for an appointment. 508-398-2212
Other
Appropriate plans and/or application shall be provided to each departments checked-off above.
Each of these regulatory authorities has the r own requirements outside the jurisdiction of the
Building Department. All applicable approvals shall be obtained prior to submitting a building
permit application to the Building Dept.
Thank you for your cooperation.
Receipt Ackn wle , ment:
Applicant's Signature Date
Rev.Jan. 2019
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-223[1 ext.-1261 Fox 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. 144.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at t S ') L).-0 -Ak-S
Work Address
Is to be disposed of oat the following location: L. y o 04-
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
Y �,f cZ— ztC — ZZ
Signature of Application Date
Permit No.
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AF'.':.:2.;:i-,T :.:,:.CM THL RLSVONSIBILITY U:' ',:.,::':BUILT"
COMPLIANCE.
DATE: - -2'13
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BUILDI G OFFICIAL
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