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HomeMy WebLinkAboutBLD-23-005500 1T(EC E1 FD or-- • BUILDING PERMIT APPLICATION 1 •A .c APPLICATION TO CONSTRUCT REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, APR .it.alti G OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. Town of-Yarmouth Building Department BUILDING = ^' 1146 Route `_8 • Yarmouth, MA 02664--Nc)2 3y Tel: 508.398-2231 ext. 1261 Fax 508-398-0836 8/ Z O Ilse Onty I Planning Board Information Assessors Department Information: Permit No. 3 �a Date Plan Type_ I Ma LDI ra �C (Endorsement Date " •, , Permit Fee $ � ��.I. / ��n ( Deposit ��`r` y�� : othn Date New • n No. 1.4 Property Dimensions: i I Net Due $ \ \ C j Other Lot Area(st) Frontage(It) Lot Coverage This Section for Office Use Only Building Permit Number. Date issued: Signature: --/ =✓ .// -) I 1 Certificate of Occupancy Building Official Data• — is is not required Section 1 - Site information 1 1.1 Prop erty rtY Address: 1.2 Zoning Information: ic>ciA A r 1 5 Y o--r"\C t tAN c).;t(. tn4_ Zoning District Proposed Use 1.3 Building Setbacks (ft) Front Yard I Side Yards ' Rear Yard Required I Provided Requi-ed ± Provided Required i Provided I i 1.4 Water Supply(I61,Q.tL c.40.S 54) 1.5 Flood Zone information: Comments IPublic Private I Zone: - BEE Section 2 - Property Ownership/Authorized Age-nil 21 Owner of Record: APR 14 2r123 Name(print) Mailing Address: BUILDING DEPARTMENT I Signature Telephone Telephone sy 12.2 Authorized Agent: Emal e_ .'�/ I j Name(prfntl Mailing Address: Signature Telephone i Fax Email Address: 1 Section 3 - Construction Services I 1 3.1 Licensad Construction Supervisor. I Not Applicable D I i -1- ; CA( i S T AXE pc)c I 1 '1 0 N PA. : VI S f�- License Number 2 / _ I Address / C 3 � � _L3 �^ 1 '.- -- --- sOr3/V )).,/ r� C«e'r! ;,cam"/= r ,).„.,., Expiration Da I Signature Telephone Email Address: i 4 C.t)G ie-v-\po r±t,U-C. e__., q m c, _ co►r►a1 { fA • • • • • • • • • • s3 e z t 4 ..�,.. E IS1 .I 99:; 1 • Section 6 - Description of Proposed Work(check alt applicable) New Construction O I (tor multiple family only) No,of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ,] I yAlterations 13t- Repair(s) Addition ❑ f Accessory Bldg. 13 Type +Demolition Specify: Other S eci f i Brief Description of Proposed Work: i 0 I 20 in Q '?,uc.Cy\ 1\�e ‘ r PD fi..ii c-; t o M c,J r roan CA I-a.c-1�� 11 ��in., e- f�CA L I1W'•a cS C. f"') 4.._.4 1_S':n� , c�sC.1vC� _ K 4y6 � , (. c.c.- 1cv ? r. w-ta.n G M 0I L , - Al d ��' rn �..n , Section 7- Use Group and Construction Type Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ' ❑ A-1 13 A-2 0 A-3 ❑ r IA j I A-4 0 A-5 ❑ 1 B CI B BUSINESS D -A ❑ I E EDUCATIONAL p 28 D F FACTORY 3 F., D F-2 0 2C 0 H HIGH HAZARD 0 3A 0 }I INSTITUTIONAL 0 I-1 0 4 2 0 I„ 3B 13 I M MERCHANTILE p4 13 i R RESIDENTIAL 13 R-1 0 R-2 0 R_3 3 SA 0 S STORAGE (Q S-1 ❑ 5-2 0 Sg D U UTILITY ❑ SPECIFY: M MIXED USE SPECIFY: I S SPECIAL USE I 0 SPECIFY: !Complete this section if existing building undergoing renovations,additions andfor change in use,I I Existing Use Group: I Proposed Use Group: IExisting Hazard Index 780 CMR 34 i Proposed hazard Index 780 CMR 34 Section 8 Building Height and Area Building Area Existing(i1 applicable) Proposed Number of floors or stones include basement levels II Floor Area per Floor(st) Total Area All Floors (sf) 7 1 2 I Total Height (ft) 7, el I Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required ?es No I SECTION 1 Oa OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I I, , V1, ^ , as Owner of the subject property, `` hereby authorize C 1S P �'1' . Z.V1 tti c c- ) t0 act on my behalf, in all matters relative to work authorized foy this building permit application. jIXC2— — �tb-5e of Owner Da 1 r• 4 3.2 Registered Home Improvement Contractor: Company Name 1 Not Applicable 1 1 Address Registration Number I Expiration Date i Signature Telephone I i 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: Not Applicable D Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineers I Name Area of Responsibility Address Registration Number Signature Telephone f Expiration Date • Name Area of Responsibility r Address Registration Number i Signature Telephone 1 Expiration Date I Name Area of Responsibility 1 iAddress Registration Number 1 Signature Telephone Expiration Date i Name Area of Responsibility 1 IAddress 1 Registration Number Signature Telephone Expiration Date f Section 5.3 General Contractor 1 INot Applicable ❑ Company Name ;� C h.1 4JJ�.v 0,1 IG r Person Respons�iple for Construction .-A w N NI , S,T Address Signature Telephone 1 \, SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION T ` I, 1 �rrl �, L'O(�` I ',IN , as Owner/Authorized Agent hereby declare that the state-eerits 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. '6_,e‘ L0�c ►1\. ✓1 Print Nam Si re of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be { completed by permit applicant 1.Building 2_Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection 6.Total=(1 -2+3+4+5) 7.Total Square FL Om new farm-rums&afteewa) I Check Below i❑ Conservation-Commission Filing (if applicable) I ❑ Old Kings Highway& Historical Commission approval (if applicable) The Commonwealth of Massachusetts l—.,„,4—. Department of IndustrialAccidents 1 Congress Street, Suite 100 v. i 41 Boston, MA 02114 2017 47 ,.s.'•"' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TEE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): I4.)4. CR0c L '..Rt( Scc . Address: ` TCU IU S Y,,c ,G&-1- 1 c l City/State/Zip: S �ofIv\ov 4 A o f Phone #: 50Z D.S 7 y 1 1 Are you an employer? Check the appropriate box: Type of project (required): 1.E I am a employer with_ i 0 employees(full and/or part-time).* 7. New construction 2.Q 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. t 9. ❑ Demolition ❑ g y [No workers'comp.insurance required.) 4.0 1 am a homeowner and will be hiring contractors to conduct all work on mYproperty. 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.: 1 3.ERoof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.d0t[]er CIA �'I' rci �?� 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. Insurance Company Name: L J6c c S} cofil %e..c \(NS L,c c'...‘ Policy#or Self-ins.Lic.#: 4 C.C 5 \t‘J C OQc 75- 1 Expiration Date: Ili ) D-9 itJob Site Address: .3 I ocJc11 S Yd.r moo M K Oft (e.,`-I City/State/Zip: S Yar ino4t MA cp,c1,11 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 th pains and penalties of perjury that the information provided above is true and correct. Date: lijiIa. � Phone#: �50 8 7 c)y I 1 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 508-398-22311 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 -FU b ' ik S ya.,r'10✓ ' t', M 0 G µ Work Address Is to be disposed of oat the following location: C h, l c\ 5 I G) GJ 1 k L A :aY►ni 1, MIS c):x o Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. /. 431 g -- nature of App ication D i o Permit No. - " i../ -it s • .47, ,, Irc , - P- , �,�{ d. x; ' ' . t '‘k. I 4,,,,,„,„,,eik 1, f.,-i *'' ,t0170 r: AV it r a. i. (0,y OTOWN OF YARMOUTH �\o``� WATER DEPARTMENT y 99 Buck Island Road �n West Yarmouth, MA 02673 Telephone: (508) 771-7921 • Fax: (508) 771-7998 BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OFF TRANSMITTAL FORM BUILDING SITE LOCATION: 1 9__TocU It 5 �� rho(,11 " N PROPOSED WORK: I"on fPU M ID Rvo 9,a r APPLICANT: 1.. air\ L) 1-o v 1 p `1 � \, ADDRESS: 1 To dU I\� S / a c w%oo* MI\ oa6(,,4 TELPHONE: 503 3 7 0 -1 1 t RESIDENTIAL AND /OR COMMERCIAL BUILDING Water Department: Determines Compliance of Water Availability and or existing location Engineering Department: Determines Compliance for Parking and Drainage Conservation Commission: Determines Compliance to Wetlands Act; i.e. If lot(s)border any type of wetlands,streams,ponds,rivers, ocean,bogs, boys, marshland, ETC... Health Department: Determines Compliance to State and Town Regulations, i.e. requirements for Septage Disposal and other Public Health Activites Fire Department: Determines Compliance to State and Town Requirements for Personal 07,_ Safety, Property Protections, i.e.c.,00±1 .,v, „..,,Smoke Detectors, Sprinkler Systems,etc 5oa a379 "I [ 1 saclIs6 -5Iv..., , AP ' CANT SIGNATURE DAT OFFICE USE: COMMENTS ON PERMIT APPROVAL OR DENIAL REVIEWED BY WATER DIVISION(SIGNATURE) DATE 3/31/23, 10:45 AM 26 Todd Rd-Google Maps Go gle Maps 26 Todd Rd Yarmouth,Massachusetts '" , . Google Street View i t� �p1 ``,i a a4« ^! v r :r �`�y i Oct 2019 See more dates +� t a., + ` , ' r *.� -1- ' k - • • i ' - ~•lt 'A t �•. Y1" .>` .ry m9,,. « ill'i ;' • ,.s A r e. :i i _ - , o� ,s ?. Y vita „ ;«? r. t l4Y ri • + ,,,�,...,; ... , 4 we" :-- ,�.t�.� �'impirr w•• -� t .111011 go. �.. ....sH �., _ fu(nlultliaweel anul..aaim. '^t j • .. 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Moesadwsetb 02632 Drown By: MC Date:— Drawing Scale: AS NOTED Rev 0 Cot yAlt-t I' yr 144 S File Nomeoject No.: � —