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HomeMy WebLinkAboutBLD-23-004761 • ' of•Yq,i, BUILDING PERMIT APPLICATION • -�CE 'zrO APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, oF•� C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. .� TTI,C:1'1C_�� y�•• Town of•Yarmouth Building Department MIC3 �,t,,.„* 1 146 Route 28 • Yarmouth, MA O2664-•1•492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836.9 / V E D ice Use On Planning Board Information Assessors Department Information: r3L, ' z Off�� y �/ pt 1-E 2 7 23 I Permit No. Date Plan Type Map Permit Fee $ Endorsement Date Lye� EPA NT Recording Date ) gviira l► y \j Deposit Rec'd. $ 00_00 Date- . a Plan No. 1.4 Property Dimensions: Net Due h Other_ Lot Area(sf) Frontage(ft) Lot Coverage This Section for Office Use Only Building Permit Number. Date Issued: Signature: . Certificate of Occupancy Bbir n Official • Date is Is n t R E C 444941E D Section 1 - Site Information 1.1 Property Address: ��dai 1.2 Zoning Information: —�13 2023 /149,MV kill Y.(2/ Zoning District ny - o0___ f 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required I Provided 1.4 Water Supply(M.G.L c.40.S 54) 1.5 Rood Zone Information: Comments Public X Private Zone: BFE • Section 2 - Property Ownership/Authorized Agent 1 2.1 Owner of Record: 7715/11 Na367-C /j 24?4 _ zc P"ve czev five lifiN , Name( n t) /t..6) Mailing Address: 4,2 D Signature Telephone /SDiUS zLe Telephone Email Address: 2.2 Authorized Agent: r714/9715g ii‘l/ C/i/, -)/ 4/ i '2-1) -41) 4,614tJ1/1 Na a (print) Mailing Address: /g1 ' 4 ga -1.) �C�Li2 J? -a2 / / 1) /-717 yd7 7L <_'vrhi,AG f ib Signature Telephone Fax Email address Section 3 - Construction Services 3.1 L ensed Constructiiop 3 p.r,isor. Not Applicable j /2J5 , JLicense NuAAd ress �(l� /�� 1���� pzieiza, di?, :i� ,��M(i cG/Y A ,�4 Expiration Date Signature Telephone Email Address: • 3.2 Registered Home Improvement Contractor. Comp ny Name 1 Not Applicable ❑ - C Address Registration umber Jlo �� � I'''�//:'-/��"" / Expiation Date //if Signature Adi��G ephone j f/5 — 9( j "t/ 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 to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Architect: i Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s) Name Area ot Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Ham* Area ot Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor 1 Yzerazi)%a+ee .t�� izzi e Comps y Name / Person 37ze for Const t' n / 4 � Ad ess ��- — 1 /� Signature i ra Telephone Not Applicable , 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. 4 Repair(s) ❑ Alterations A Addition ❑ Accessory Bldg. ❑ Type I Demolition Other Specify: P fY: I Bri jf Description of Proposed Work: /f d ,y�, 4 _,,h/ - - , zi-3/ ,g_/6""a9w -A/,,,,ize ,_,.p 9.*vel d _44-A-frazd Lzti) ,44/4y1,- ./) ,,40.44isy ,29/,„drif4fzicyJ J Section 7- Use Group and Construction Type J Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A-4 ❑ A-5 ❑ 1B ❑ 8 BUSINESS 2A ❑ E EDUCATIONAL ❑ 2B ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 Zl R-3 ❑ SA ❑ S STORAGE ❑ S-1 ❑ S-2 ❑ 53 ❑ U UTILITY CI _ SPECIFY: M MIXED USE ❑ SPECIFY: - S SPECIAL USE ❑ SPECIFY- Complete this.secti?n if existing building undergoing.renovations;additions and/or chang in use. ExistingUse Group: ' ./ '/� ' /�"� "�' J' r,� Proposed Use Group: Existing Hazard Index 780 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 include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height(ft) Section 9 - STRUCTURAL PEER REVIEW (780CMR 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, FneOcif>ros /d o 11-_ , as Owner of the subject property, hereby authorize 47Lt!� i` h4 - to act on my behalf, in all matters relative to work authorized by this building permit application. -----... 4,,,..,4., ‘44,6_,./) . :2- ) 7 - ,),2 Signature of Owner Date SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION I, 1��.�%1 iz �ih-e ,�� , 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 pain and penalties of perjury. Print Name 7/" fi a 1)14(44 7/i3 Signature of Owner/Agent ate Section 11 - ESTIMATED CONSTRUCTION COSTS Item • Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2.Electrical klG 3.Plumbing I Gas /Jc2 4.Mechanical(HVAC) 5.Fire Protection Azi® 6.Total=(1+2+3+4+5) • 7.Total Square FL(tor new smctices&additions) Check Below ❑ Conservation-Commission Fling (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) • The Commonwealth of Massachusetts i r Department of Industrial Accidents 1 Congress Street, Suite 100 11/4tzur Boston, MA 02114-2017 ..SY•�,, 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/ dividual):� GGdd// �` J /G�r� Address: ,e12 d &i,/?4g,09,4ef.City/State/Zip_ie :/`�� 2 d h #: e'-' -- Are you an employer? Check the appropriate box: Type of project (required): 1.k; I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.) 8. remodeling 3.0 I am a homeowner doing all work myself. t 9. E Demolition y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on m YProPenY• 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. 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.1 13•n Roof repairs 6.0 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#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 my employees. Below is the policy and job site information. ,,,6) . Insurance Company Name: / /,01 Policy# or Self-ins. Lic. #: 16 ,.R2 //b/70gi-,47 i _<i---vU Expiration Date: ......1.--/57,,t 1 Job Site Address:ZW , eledir City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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 ndpenalties of perjury that the information provided above is true and correct. Si natureL> p,'�,� je."/ ,�" Date: /% ;..g Phone#: 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. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5 I hereby certify that thee ddebrisresulting from Qthe proposed work/demolition to be conducted at p�J( A,c1lt�;GiL���=fi'�P i� �tC ► Cal."46kal6 Work Address Is to be disposed of at the following location: 3 i ...//�� ��re Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 0001 Signature of Applicant Date Permit No. 06/16/2022 10:31 Howe Insurance (FAX)9784752171 P.001/001 GATE (MR1+DD1riYY) ACORLY CERTIFICATE OF LIABILITY INSURANCE 1 Es/1 SWD22 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND TEIE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Sullivan Insurance Agency PRODUCER Phone: (97B)851-9600 Far (978)475-2171 CONT SULLIVAN INSURANCE AGENCY PHONE (NC,Ne.Ea31: 078 851-9600 Fc Net, (978)475-2171 4 PUNCHARD AVENUE E.MA:L ANDOVER MA 01810 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# INSURERA : Evanston Insurance Co 'THOMAS INSVRERe : Ace American Ins Co j THOMAS A HILCHEY DBA THOMAS A HILCHEY CONSTRUCTION INSURER c : 26018 82 OLD CHATHAM ROAD INSURER 0: HARWICH MA 02645 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 36950 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEDPo BY PAID CLAIMS.I LIMITS 'WSR ADD'Ll still POLICY NUMBER rMoLICY YEFT rPOLIC EXP LTR TYPE OF INSURANCE INSR I vw 1,000,000 A GENERAL LABILITY 3AA506580 09/26121 09/26/22 EACH OCCURRENCE s DAMAGE TO RENtS0 $ 100,000 I PREMISES(Ea sesurence) X COMMERCIAL GENERAL LIABILITY JCLAIMS N ADE MEO.00P(Arty one Person) S 5,000 OCCUR PERSONAL&ADV INJURY .S 1,000,000 GENERAL AGGREGATE S 2,000,000 — PRODUCTS-COMP/OP AGG S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER $ PRO- - LOG POLICY n JECT �— COMBINED SINGLEUMIT (Ea ac tdern) $ I AUTOMOBILE LUtBILITY _ BODILY INJURY(Per person) S ANY AUTO _SCHEDULED BODILY INJURY(Per accident) S —ALL OWNED,_AUTOS NON-OWNED AUTOS PROPERTY DAMAGE S HIRED AUTOS --- (per acRTY AUTOS $ I — EACH OCCURRENCE $ UMBRELLA UAB _1 OCCUR EXCESS LIAR CLANS-MADE AGGREGATE SADE $ • DEO} `RETENTION S (WC TORY UM TS I I OER TH S B WORKERS COMPENSATION 6S62UB-4N92588-6-22 05/05/22 05/05/23 AND EMPLOYERS' LIABILITY YIN E.L EACH ACCIDENT S 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER!MEMBER EXCLUDED? NIA E.L DISEASE-EA EMPLOYEE S 100,000 (Mandatory In NH) E.L DISEASE-POLICY LIMIT $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS beIPP • DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Thomas Hllchey is excluded from the workers compensation policy CERTIFICATE HOLDER CANCELLATION Town of Dennis SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ;t:e-46/ ..„ Attention: 774-408-7127 David T. Louis ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstWdtth>tt iiptrvIsor CS-034718 P * 4/pires:09119/2023 THOMAS A H1LCH 7 82 OLD CHATHAM • ! t HARWICH MA-;02•, ( O Q/ `"fit Commissioner diI e• 8tna THE COMMONWEALTH OF MASSACHUSETrS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation TYPE:Individual 1000 Washington Street -Suite 710 Registration10649 11/Expiration/224 Boston,MA 02118 110649 ;_ +-.,E`71/02/2024 THOMAS A. HILCHEY ._ II ''` kv t r /ny 1' THOMAS A. HILCHEY ,' V�/�� f. 82 OLD CHATHAM ROADS ry 6,� Ci i °4 HARWICH,MA 02845 ~-�4-*. fr' Undersecretary Not valid without signature • iccukr ! „ 3©'4x. 7`d " Central Cape Giass 10" 4DA o Thar 104 South Dennis, MA ctect r oknodt . tvust t 5a8-385-2235 A f„' gL .e. - vu -Te,,&prdt. F ro.n t- Reg f6.\ Yciz , oi-t,t,r_i2._ li t 1 1. i ii Ij t if 1 , i 1 t 1 /Oaf : 1 .+ ?0' . i I. _ _-__.___---__ ---_ ______ 1� __--- ?a7/9