HomeMy WebLinkAboutBLD-23-004055 /2C ' -/<,L7/ /3
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BUILDING PERMIT APPLICATION
• APPLICATION TO CONSTRUCT REPAIR, RENOVATE CHANGE THE USE, OCCUPANCY OF,c OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
( ,TTcnvn ut•\Lrrltouth Building Degtrtnr-.,••T?,Cd 1146 Route 21.; • Yarmouth, MA 02(i64-1492
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836
Office Use Only Planning Eoard Information Assessors Department Information:
Permsl .3-°b (;Date Plan Type_ Map Lot
Permit Fee Endorsement Date /
$ ��� Recording Date New
Deposit Rec'd. $—\ Date Plan No. 1.4 Property Dimensions:
Net Due $ �3� Other -
%�'s/y Lot Area(sf) Frontage(ft) Lot Coverage
•
Building Permit NumberThis Section for Office Use Only
Date Issued:
Signature: ../ . Certificate of Occupancy
Bw fficial Date is Is not required
Section 1 - Site Information
1.1 Property Address; 1.2 Zoning Information:
•
127 Whites Path
South Yamrouth MA B3 Public Utility .
Zoning District Proposed Use
1.3 Building Setbacks (ft) -
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required 1 Provided
30 750 10 135 50 635
1.4 Water Supply (14.G.L e.40.S 54) 1.5 Flood Zola Information: Comments
Cubli> Private Zone: _NA BFE NA Not in a Flood. ZOne
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Record;
Boston Gas Company, D.B. National Grid
Name (pri t) — 40 Sylvan Rd, Waltham, MA 02451
Ci% Mailing Address:
LGP/2.GyL
781-907-1000
Signature Telephone Telephone /
Email Address:
2.2 Authorized Agent:
Michael E Guerin 170 Data Dr Waltham, MA 02451
N • (p int) Mailing Address:
Cfre/A1.41.-.
Signature Telephone Fax
Email Address:
Section 3 - Construction Services
3.1 Licensed Construction Supervisor. Not Applicable
Arianna Jesi
240 Newbury St, Danvers MA 01923 License Number
Ad ress CS-111131
978-778-8411 ajesi@united—civil .com Expiration Date
Signature • Telephone Email Address: 2/2 8/2 3
3.2 Registered Home Improvement Contractor:
Company Name Not Applicable 511
Address Registration Number
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 G) 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
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
Section 5.2 Registered Professional Engineerls)
Rea A. Huston
Name Area of Responsibility
8204 Balata Dr.,Ooltewah,TN 37363 Process/Mechanical
Address Registration Number
YY �� 912-330-5264 46010 Chemical
Signature Telephone Expiration Date 06/30/2024
Randy Maccaferri
Name Area of Responsibility
440 S Church St, Suite 1200 Charlotte,NC 28202 Structural
Address Registration Number 309493
Kairclf Naccale��i. (704)338-6819
Signature Telephone Expiration Date 06/30/2024
Paul K. Davila
Name Area of Responsibility
613 NW Loop 410, Suite 700 San Antonio,TX 78216 Electrical
Address Pau U nalfriA (210)841-2902 Registration Number 52518
Signature Telephone Expiration Date 06/30/2024
Name Area of Responsibility
Address Registration Number
•
Signature Telephone Expiration Date
Section 5.3 General Contractor
United Civil Not Applicable ❑
Company Hame
Arianna Jesi
Person Responsible for Construction
240 _Newbury _St, Danvers MA 01923
Address 11 /e,-- 978-778-8411
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. ❑ l Repair(s) ❑ I Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
South yarmouth boil off compressor Upgrades .
Cain.,-.-ruct nPw ROG System. Work includes foundations, structural
steel, piping, Instrument and control, electrical and integration of
new BOG system.
Section 7- Use Group and Construction Typjal
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 ❑ 2A ❑
E EDUCATIONAL ❑
2B al
F FACTORY ❑ F-1 ❑ F-2 ❑ 2C
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S STORAGE
❑ S-1 ❑ S-2 ❑ se ❑
U UTILITY 31 SPECIFY: Public Utility
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:Boston Gas Company D.B. National Grid Public Utility
Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area Instrument Air Building
Building Area Existing (if applicable) Proposed
Number of floors or stories
include basement levels 1 Floor
Floor Area per Floor(st) 167 SF
Total Area All Floors (sf) 167 SF Total Height (tt) 9 ' 8
Section 9 - STRUCTURAL PEER REVIEW (78DCMR 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
Michael E Guerin
, as Owner of the subject property,
hereby authorize United Civil to act on
my behalf, in all matters relative to work authorized by this building permit application.
•
January 18, 2023
Signature of Owner Date
SECTION y Ob OWNER/AUTHORIZED AGENT DECLARATION
Michael E Guerin
1, , 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.
Michael E Guerin
Print Name
•
(9u&= . January 18, 2023
Signature of Owner/Age Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
a Electrical
3.Plumbing/Gas
4.Mechanical(HVAC)
5.Fire Protection
6.Total=(1 +2+3+4+5)
7.Total Square Ft.(tor news rooms 6 additions)
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway& Historical
Commission approval
(if applicable)
The Commonwealth of Massachusetts
Department of Industrial Accidents
r' =� � 1 Congress Street, Suite 100
_;1.0W Boston, MA 02114-2017
w ww,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): A - C \.; n �
Address: ^1 G 1\-' ,; �1 �! -e 21-
City/State/Zip: (11 i 11 Al��'�,/� i�"/_ Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
LEI I am a employer with employees(full and/or part-time).* 7, E New construction
2.:I am a sole proprietor or partnership and have no employees working for me in 8. — Remodeling
any capacity. [No workers'comp. insurance required.]
9. E Demolition
3.0 I am a homeowner doing all work myself. [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 I l.[ Electrical repairs or additions
proprietors with no employees.
12.ri Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet I3.❑Roof repairs
These sub-contractors have employees and have workers'comp. insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
l 52,31(4),and we have no employees.[No workers'comp. insurance required.]
*Any applicant that checks box lil must also fill out the section below showing their workers'compensation policy information.
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 smte 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: �C 1��+\2,\'`� tL �� �L'.. �� C C..
Policy# or Self-ins_Lic. #: \n/ S 31-, s l (./ Expiration Date: ( 1 / /,E' / )
Job Site Address: 137 Whites Paths City/StatelZipSouth Yarmouth, MA 026E
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$1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si ature: Date: 12/2 8/2 2
Phone#: 978-778-8411
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City,Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext.-1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 127 Whites Path, South Yarmouth MA
Work Address
Is to be disposed of oat the following location: 1)(A k'l
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
I 7/c)23
i nature of Applic Date
Permit No.
i * Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
C ons$tuttiilpvisof
3
CS-111131 �: 7" 4cDires:
ARIANNA JEST .:4
36 WATKINS WAY-1., 0
MIDDLETON MA 0.11
/f1()}t,,il0 'S!'�a
Commissioner rjai4 K WEmcha,
i
I
MGt_AND FII'l:
' RNO�'T y TOWN OF YARMOUTH
, , \� REVIEWED EDF CO +`M',.14 r,,1
1 ERRNS ORGUMSe +"roc;0 1`1 1 E
1 `'i.r�;I yi r„1- # r a is D c r.:t ill i 3 ff
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•
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YARMOUTH FIRE PREVENTION
Commercial Construction Building Transmittal
Project Name: National Grid Address: 127 Whites Path
Contact Name:Sophie Forde Phone:617-823-7523
Description of planned project: replace and add steel building and
1 Y N NA Sub,�ect _ Regulation I
X Access for Fire Apparatus 527 CMR 1;18.2.4.1
X Building Numbers MGL C 148;sec 59
X *Flammable gas/liquid storage 527 CMR 1;42.2.2.1
X Fire Lanes 527 CMR 1;22.3
X *Service Stations 527 CMR 1 ;16.2.3,16.2.3.1,30.3.2
X *Hazardous Materials Storage 527 CMR 1;60.1
X *Kitchen Exhaust Systems* 780 CMR,527 1;50.1
X Extinguishers 527 CMR 1;13.6,MGL C 148;sec 28
X Fire Alarm Systems/CO detection' 780 CMR,MGL C 148;,527 CMR 1; 13.7
X *LPG Storage Chapter 148;sec 9,10,28&527 CMR l;69.1
X Use and Occupancy(FH Building Class) 780 CMR;302.1
X Sprinkler Systems* 780 CMR&Chapter 148 sec 26 A-I
Storage inside/outside Buildings 527 CMR 1;10.19.4,4.4.3.1.1,19.1.2,34.1.1
X *Upholstery 527 CMR 1;20.6.2.5
X *Trash Containers 527 CMR I;19.1.1,1.12
X Any Hazard to the Public MGL Chapter 148;sec 28
X *Curtains,Draperies,Blinds 527 CMR 12.6.2
X Safeguarding Construction NFPA 241,527 CMR 1 Ch 16,16.3.1,2; 16.3.4.1
X Hot Works Permit,where required 527 CMR 41.1.5.3
*YFD permit required-depending on occupancy and submittal
Regulations based on NFPA 1(2021 edition)with Mass amendments adopted 12/09/22
Compliance with the following:527 CMR 1 Chapter 16"Safeguarding Construction,
Alteration,and Demolition Operations."780 CMR Chapter 33
*Permit is required for temporary shutdown,alterations or proposed removal of fire
protection systems.
Yarmouth Fire Department supports the application,subject to applicable submissions,
permits and inspections.
Plan Reviewed By:Lieutenant Matthew Bearse Date:February 15,2023
Copy for Applicant 0 Copy to Building Department Copy to Fire Prevention l I
Entered in Firehouse I-1 Final Inspection I 1