HomeMy WebLinkAboutbld-23-003654 /9 Gf i/glL3
. .• oF•YaR BUILDING PERMIT APPLICATION R G IL
• . •., APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE S OCC: PA � D
y.
o ; _I:, _y OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMIL D EL.
--m ,Z. Town of Yarmouth Building Department f�' 03
MdTT�Cti[CS �{, Ar a
% 'k•....,,.•* Tel: i 146 Route 28 • Yarmouth, MA 02664-4492 BUILoov *t p�.)�.�
508-398-2231 ext. 1261 Fax 508-398-0 R rMENT
�-23 ffi se Dn Planning Board Information Assessors Department Information:
PertU No. Date Plan Type Map Lot
\ J\,
V Endorsement Date /
��Permit Fee $ 0,k3
\\4.,\213
Recording Date New
Deposit Rec'd. $�b•Cfa Date Plan No. 1.4 Property Dimensions:
Net Due C $ kC10,(,c� Other
Lot Area(at) Frontage(tt) Lot Coverage
e f''e 1( 1 This Section for Office Use Only
Building Permit Number. Date Issued:
Signature: . %� �. I (- ,- , . Certificate of Occupancy
Building official Date is Is not required
Section 1 - Site Information
1.1 Property Address: 1.2 Zoning Information:
RA CM)CM)E pktw t c. cti,k) ` .
IG3 W\,‘,.ke5 Pqtkt‘ t \Ctr'IMt *'\ k'R Zoning District Proposed Use
1.3 Building Setbacks(ft) OtC`(
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.4 Water Supply(M.a.L c.40.S 54) 1.5 Flood Zone Information: Comment&
Public Private Zone: BFE:
Section 2 - Property Ownership/Authorized Agent
\ 2.1 Staner of Record:
G et A\ & i60 ?ate; 5=fair AAA
Name rint) Mailing Address:
2._ ,
Signature fps-�(�!y 512� 4-3`6 ti
9 lephone Telephone Email Address:
2.2 Authorized Agent:
•------- tA P‘AT-kivQLO C IAA e y w•oik IA e,ap elm e,ie .6,L,./.:.i . c CA401
Name(print) • Mailing Address:
SC)8-221- -1388
Signature Telephone Fax
Email Address:
Section 3 - Construction Services
3.1 Licensed Construction Supervisor: Not Applicable
ij
'nh,v 1 Cc,1 I cAl evv1
License Number
1 i :.t}�erc.4 CAN% 5 `(arw�o•.-iL► Cif, o2E6 Li
Address (� , ' C _ k 1C)�Z,q
< <�Vk. e cAni\ •- 4-`� -GLIGI CcoAaha„,-IC Expiration Date
Signatue Telephone
Email Address: 01 11b I ZbZ(,
CdhA A C`�I- t\�� gvv�r.i .CGvY\
c
_3.2 Registered Home Improvement Contractor.
Company Name Not Applicable ❑ • -
Registration Number
Address
Expiration 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
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:1
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
Address
Area of Responsibility
Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor 1
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. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. D Type Demolition Other Specify:
•
1
Brief Description of Proposed Work:
tv Lc...I c.,„4- C1ic,.i .5 .C_ A i,,,--ccv ` 12 wto cam.\/
,
Section 7 - Use Group and Construction TypiJ
Building Use Group (Check as applicapable) Construction Type
A ASSEMBLY O A-1 ❑ A-2 ❑ A-3 ❑ 1A
A-4 ❑ A-5 ❑ 1B 0
B BUSINESS 2A ❑
E EDUCATIONAL ❑ 2B
F FACTORY ❑ F-1 ❑ F-2 ❑ 2C
H HIGH HAZARD ❑ 3A D
I INSTITUTIONAL ❑ I-1 D 1-2 ❑ 1.3 Q 3B ❑
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL ❑ R-1 ❑ R-2 R-3 ❑ 5A
S STORAGE ❑ s-i l3 S-2 ❑ 53
U UTILITY U
SPECIFY:
M MIXED USE CI SPECIFY:
S SPECIAL USE DSPECIFY:
Complete this section if existing building undergoing renovations, additions and/or change in use.I
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area I •
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 (7EIOCMR 110 11)
Independent Structural Engineering Structural Peer RevieN Required Yes No
SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, jA-cr� > , as Owner of the subject property,
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building pen-nit application.
0lam--� --Z___ r1 q 'Z .Z
Signature of Owner Date
1 n! A
r - +
SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION
I, - P..D.15.14 . , as Owner/Authorized Agent •
hereby declare that the stat 'rr4.nts 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.
•
Print Marne
-RtAbk,t.a-,C) k/2/2-3
Signature of Owner/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
5,coo
a Electrical
3.Plumbing/Gas
•
4.Mechanical(HVAC)
5.Fire Protection
6.Total=(1+2+3+4+5)
7.Total Square Ft.(tor new srnctures a additions)
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
. The Commonwealth of Massachusetts
2? 1, Department of Industrial Accidents
- 1
w 1 Congress Street, Suite 100
'1I:1 Boston, MA 02114-2017
• 5�•`'t 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): T C. C ol\-ts-c.cko c s /
doti I c c,I Lc
Address: 1 (3(Att. 6-cut? L.cone
o r.Gcy
City/State/Zip: S(,L,.kt., `{ter v,.,o L,411 tigc Phone #: 11 -36.3 -C0401,
Are you an employer?Check the appropriate box:
Type of project (required):
l.1:1 I am a employer with 0 employees(full and/or part-time).* 7. ❑ New construction
2.D I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity. [No workers'comp. insurance required.]
3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
10 ❑ Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
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.1 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(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.
Insurance Company Name: 6, b e c-k
Policy# or Self-ins. Lic.#: t•Ici WC 8033 e•'1 Expiration Date: i 0I 15 1'D2 3
7
Job Site Address: ICt'3 l.�%k'k...T"E.E � & , i City/State/Zip: S `(e;rwuec;,}t, ri'l#t o Zu..q
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 and nalties of perjury that the information provided above is true and correct.
Signature: kid, �,„1y",,� Date: o% o3I207-3
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#:
• 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 who 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
508-398-2231 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 \C ... #CS P o - , c-,nvAk„ mco`, , k\ o Z(hcl
Work Address
Is to be disposed of oat the following location: '(c,/kmoc.\\A c ccoAscec 51Pv\ic'\
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
CI FLO Z,3
Sign ture of A lication Date
Permit No.
. Massachusetts
Common
Berd of
Divisulations and Standards
• •Commonwealth ot
Regulations li ion of ProfessionalLicensure
Building
Construction Supervisor
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Cs..110429
, Expires : 07/ 18/2022
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JOHN T CALLAHAN, IV
MONO
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-1 BUTTERCUP LANE
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SOUTH yAR .
m9UTH MA 0
2664
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AC CERTIFICATE 0 LIABILITY INSURANCE DATE I
fie..,/' 09/27/20222022
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 POUCIES
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