HomeMy WebLinkAboutBLD-23-001721 - . --F•Yq,q BUILDING PERMIT APPLICATION
. • APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF,
'. .ei; jji�s • C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Y - - ,. Town ofYarn-unnh Building Department
14atT71C 7.
,.• �@ 1146 Route 28 • Yarmouth, MA 02664-4492 R iC EVE 0
Tel: 508-398-2231 ext. 1261 Fax 508-39 0r-�— -�-._.--_.__
��j Office Use Only Planning Bcard Information Assessors Department Info art n: SCT 2 22
"'� 20
Zi�j'u u 1 1�i Plan Type_ Ma to_ -Permit No. Dateg ILol N f
f Plan No.
Endorsement Date
Permit Fee $ 919)fp -
NG t�E_PARTME
Recording Date New
Deposit Rec'd. $ Date _ 1.4 Property Dimensions:
Net Due $ 6J
Other Lot Area(sf) Frontage(ft) Lot Coverage
This Section for Office Use Onty
Building Permit Number: Date Issued:
Signature: ' -- 1 U" " J,� Certificate of Occupancy
Building Official Date is Is not required
Section 1 - Site Information a Q7 1--)J'GrA l as cybLt.)-p,ev
1.1 Property Address: t/J 1.2 Zoning Information: 1
R (I—luck k s\o. Qom W ems-Nchir rr A _ .
Zoning District Proposed Use
1.3 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
�� ,
Required`` Provided Required 1 Provided Required Provided
1.4 Water Supply(kt.(1.L c.40.S 54) 1.5 Flood Zone Information: Comments:
Public 0i Private l Zone: _ BFE
Section 2 - Property Ownership/Authorized Ageni
2.1 Owner of Record:
TOt. O# 'YG•'r V VIN qg . c fc (s Ifs�11d e6
Name(print) Mailing Address:
. 1.101101005 5D -771 — -N— I rusz.c1.1 a1/48y(r4-1-tx)% 4sr -rItc4•u s
Signature Telephone Telephone Email Address:
2.2 Authorized Agent:
7s0 IQ.C C� �S+• 54-t.30
Name (print) Mailing Address:
4ee4 6r% a' 16-Sic is -1ta3.5 auf1W tA 06 A0\C.,.tDM_
Signature Telephone 1t Cf✓) - i/L_ Emai( Address: i
Centerline Communications
Section 3 - Construction Services Att: Allison Conwell
3.1 Licensed Construction Supervisor 768 Southleaf Drive Not Applicable ID
Cieo-may �-t9rS . Virginia Beach, VA 23462 _
C_S-b4o
It) W e5t-CC) 1 e.-P %e1 , 11Y4r � 7 License Numberr
Address 5 S �"1�VJ
Seer L.o - • Expiration Date
Signature Telephone Email Address:
r PI
,, I A i
y:
is I 'F
4
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•
4.
•
$ 1
d
it
7
•
3.2 Registered Home Improvement Contractor
Company Name
Not Applicable ❑ � _
Address Registration Number
Eh t ton 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 1
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yesj .... 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 Si Registered Architect:
Not Applicable ❑
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
Section 5.2 Registered Professional Engineers)
Name Area of Res on ility
4- GeCt.NY..Ze N . b3 er, Mtn yV?
Addresss Registration Number
Signature Telephone Expiration Dale
Name Area Di 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
.reNe�s Not Applicable ❑
Company Ham.
Ged-C-Cre yf
Person Responsible or Construc on
to W eYr g..c0s6c�
Address
Signature Telephone
[Section 6 - Description of Proposed Work(check all applicable
)1
New Construction ❑ 1 (tor multiple family only) No.cf Bedrooms (for multiple Ifamily P Y only) No. of Bathrooms
Existing Bldg. ❑ I Repair(s) ❑ I Alterations$ , Addition ❑ ,
Accessory Bldg. ❑ Type _ Demolition Other Specify:
1
p fy:
Brief Description of Proposed Work:
A1A-1- lmoca,-C-cc�'t-i nt 1 nc.1odk re Bloc to C w-> +r,Ien e
r'ec)10.6 nS (-> 2Q-V g G.re re ov,^ (� v
W\� i JS � � tSI',1 P Xts'�in
Section 7 Use Groupand Construction
ruction Type
Building Use Group (Check as applicapable) Construction Type
A ASSEMBLY ❑ A I ,--� �y�
❑ A-2 u A-3 ❑ IA }GT
A-4 ❑ A-55 0 ;a ❑
a BUSINESS ❑ ❑
2A
E EDUCATIONAL ❑ ❑
F FACTORY 2B
❑ F-t ❑ F-2 ❑; 2C ❑
H HIGH HAZARD ❑
3A ❑
1 INSTITUTIONAL ❑ I-i ❑ I-2 D 1-3 ❑ 38 CDM MERCHANTILE ❑ ❑
4
R RESIDENTIAL ❑ R ❑
-7 ❑ R-2 ❑ R-3 ❑ SA
S STORAGE ` ❑ S-t ❑
S� �
2} ❑ 58 ❑
U Y°
UTILITY r�k SPECIFY: a. .- --t 'N M 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: Tr e_CtirYN Proposed Use Group: I e-kC. CeveYN
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area I K'//t
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) I I
Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes . No)( i
SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN I
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, f.. r ± , as Owner of the subject property,
hereby authorize C.cnler\tne_ Celmmont'cc_'�ehS (a ern#- /Tc1 to act on
my behalf, in all ,matt relative to work authorized bythis building
On C Guru Q ,b 1 permit application.
5(As --7 71_ 7 id-N
Signature of Owner
Date
e 9 i �, a3 ;,"' ",� 1$, 5 .+-ti 'ice -�d :r �s
� �,: d'�'r ter` ,, ``£ s.. �'.- a k `�' ., § y x `�,'t V x V :, , � .¢ a ""' fi -_. ,,A �# t f y#,x
-�' x` � - v"` * ' iy r•v, rK ry, -1&I V� Asw, :_ � f.,, a.v,. 33_ ,„-;* + z' ,F`r rc''t L v .
a� °5s
x7'�,�;.'?s. �..� -'�- '� :erg- - ��;'�R'a: � .'��
SECTION 14b OWNER!AUTHORIZED AGENT DECLARATION
I, OM t S0r CCC LOCA\ (A3ex..# , 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.
P(ItSor COrnwe .
I
Print Name
`�����l' CCeiAjmoot)— c4-W—Q---
Signature of Owner/Agent Date l
/Section 11 - ESTIMATED CONSTRUCTION COSTS
I Item
I Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
2.Electrical
3.Plumbing/Gas
4,Mechanical(KVAC)
S.Fire Protection
6.Total=(1 +2+3+4+5) I 5t)( 000
' 7.Total Square Ft, lxew tr smear e&a5±1,xna} I tJ
Check Below
E] Conservation-Commission Filing
(if applicable)
[] Old Kings Highway& Historical
Commission approval
(if applicable)
•
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„,' : ° 04 Wit, s', + r `t- ik molkl o A Are fs
+ l � �t s�Y -te r �. '3 . ,s ea z �`� • `"�E`xtK .
e ,,
t
f4 �'� . � i F * fit,'
r µal � .. ; * 0p � .
§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 `-18-o !?uck kbr' e_ootd
Work Address
Is to be disposed of oat the following location: Q ucATc k VicAeOrIkm
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
‘e-e61 CaeaA't
Signature of Application Date
Permit No.