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HomeMy WebLinkAboutBLD-23-005736 I` BUILDING PERMIT APPLICATION WCe • . • it.741-,;4::, 11 ". . APPLICATION TO CONSTRJCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, APR : OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWE LLING. F`_ -� '" Town of Ylrnuouth Building Department. BUILDING D •' .4....„t..� I l4fi Route 2,8 • Yarmouth. MA p2664-f492 By Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 ,�j Office Use OnlyPlanning Beard Information Assessors Department Information: Permit tVfi p_ 3-0257at� Plan Type Map Lot Permit Fee $ e t% Endorsement Date Recording Date New Deposit Rec'd. $ Ce— Date 1.4 Property Dimensions: Plan No._ / Net Due $ Other Lot Area(sf) Frontage(tt) Lot Coverage Building Permit NumberThis Sec:tlon for Office Use Only Date issued: Signature: / 9 1 L . .7) . Certificate of Occupancy ng Official Date is Is not required • Section 1 - Site Information I 1.1 Property Address: 1.2 Zoning Information: 2 I l'2-0u-r C- 2-g-i U.) I?ST Yrj/LM 0 t.r of 1 yyt)- Zoning District Proposed Use 1.3 Building Setbacks(ft) . Front Yard •� �r Side Yards Rear Yard Required Provided Required I Provided Required i Provided 7 v ,> 2,00 l 4 1.4 Water Supply MALL c.4o.S 54) 1.5 Rood Zone Information: Comments Public Private Zone: _ BFE Section 2 - Property Ownership/Authorized Agentl 2.1 Owner of Record: 3t r,i l-!-- ' L-c -S Uri 31 Imo) wb-re L✓ 2 t I1.0ct-rc 2 Name (print) ) � O Un Mailing Adqddress:: g/3,1,p 1,-.4 Morn c,, s-e-v,tCoyr 417- 7CC4- yyy� d Signature Telephone Telephone Email Address: / 2.2 Authorized Agent: /\1/4 I-/_/.) }-0 l 5-712-y 31S kocm h s.,-1 t2-C-ih D l y-I 4 f Ill H o I g 6-) Name,,(pr, 1) , Mailing Address: /(/L',G '7,g1.7 2 9.2 T V 4 Yr 6())\ @._V0 1,5 ,(O l,v1 "Signature TeleOione Fax Email Address 1 Section 3 - Construction Services 3.1 Licensed Construction Supervisor. Not Applicable l9L1ty mJ `? f?' / IS-/0/ . R e 7n V I N C f t'v) O 1 / ,-) License Number G Address 1 E� t5 -0y-1 le a G �/ / 1'1 ct H H Y\ e /'v 7 IS)l 7 2x)--7--c 44 2,0 I 94yy, tivl Expiration Date Signature • Telephone Email Addres: 3.2 Registered Home Improvement Contractor. Company Nam• Not Applicable ❑ Registration Number Address Expiration Date Signature Telephone Section 4-Workers' Compensation Insurance Affidavit(M.G.L c. 152 S 25C (6) 1 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of':he issuance of the building permit. Signed Affidavit Attached Yes f--' No Section 5- Professional Design and Construction Services-for Buildings and Structures Subject to Construction Control Pursuant to 780 CMR 115 (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 �(/tion 5.2 Registered Professional Engineer(s1i L�� C . Glof sr NameArea of Responsibly r 1 ) i0 11��j . �1't/4- Q I SC, / A i�� y, i y e e��... Registration Number ignature \ Telephone Expiration Date (,) 5 b Zti Area of Responsibility Nam• • Registration Number Address Signature Telephone Expiration Date I Area of Responsibility Name Registration Number Address Signature Telephone Expiration Date Area of Responsibility Name Registration Number Address Signature Telephone Expiration Date Section 5.3 General Contractor l Not Applicable ❑ Company Name 4 1 1 1'1 YYt 15— 1 Person Responsible for Construction r? )"R ( e_f2 ______- . \. Addles , -?�),7"2 7• Z-S`7i6 Signature .." Telephone ' , Section 6 - Description of Proposed Work(check ati applicable)I_ . I New Construction ❑ (for multiple family only) No.of Bedrooms formultl le family p only) No.of Bathrooms Existing Bldg. ❑ Repair(s) ❑ Alterations Cf L Addition ❑ [ 'Accessory Bldg. ❑ Type Demolition Other Specify: Brief Description of Proposed Work: e�Go i i j l �r F-`)C✓ \-ILk.)Y\ i 1 Y1 L -'`2/r) ({e a/vo L A-._cy ``Q/Yl Y)f, la u,v1 Section 7- Use Group and Construction Type 1 j-rL/79-- Building Use Group(Check as appOcapable) Construction Type A ASSEMBLY ❑ A-I 0 A-2 ❑ A-3 ❑ IA ❑ A-4 ❑ B BUSINESS ❑ 4.5 ❑ 1B ❑ _ E EDUCATIONAL ❑ ❑ F FACTORY2B ❑ ❑ F-1 ❑ . F-2 ❑ 2C ❑ H HIGH HAZARD ❑ I INSTITUTIONAL 0 I.1 3A ❑ l4 MEACHANTILE ❑ ❑ 1-2 CI 13 CI 3B CI R RESIDENTIAL I ❑ q-1 4 ❑ U STORAGE ElS-1 ❑ s-2-2 0 R 3 r, SB ❑ Li MIXED USE CI SPECIFY: _ • 0 SPECIFY: S SPECIAL USE _ SPECIFY: _ (Complete this.section If existing building underc_(oing.renovation.%additions and/or change In use Existing Use Group: 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) Number of floors or stories Proposed include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height (ft) Section 9 -STRUCTURAL PEER REVIEW (780CMR 110 11) I Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION -TC) BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT, I, -i ,-rlccr�4 rL .4_75/9 as Owner of the subject property, I hereby authorize /M I,1 ,..i !Y3/4—r to act on my behalf, In all m tt rs relative to work authorized by this building permit appfic ttio . Signature of Owner 3 Date SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION L. ),57(2- f , 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. ,C 1 L ) tir IY) I S T � Front Name /17A Signature of Owner/Agent 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) //ll 7.Total Square Ft horn..smcnnes&additions) / (5,-6 0 Check Below Q Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical • Commission approval (if applicable) ICY? The Commonwealth of Massachusetts • Department of Industrial Accidents 1 Congress Street, Suite 100 I' Boston, MA 02114-2017 ..r• wwrv.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): ,i- 157k,•t/ (3�S/N l Gr-leA5 Address: $ l,- 121/'�c i h a—. City/State/Zip: Rr2 i v i kin14 7 01�� Phone #: 7S-I - 7 2ti zs`- ,h Are you an employer? Check the appropriate box: // Type of project (required): LEI I am a employer with I7 employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 8.. ❑Newm construction any capacity. [No workers'comp. insurance required.] Remodeling 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 1 1.I: Electrical repairs or additions 5.❑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 1 •Ej Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14•©Other_ F y (. T. r�a I lG�ly 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: No yfe)I k. rae,,fi IVti� Vu-4 r'2— Policy#or Self-ins. Lic. #: 10 e-/2?ql$ /g- Expiration Date: 5 - 1 - 2A 2y Job Site Address: 2 6 21,,__kQ ?-r m i t ,,, ,00t 11 mq City/State/Zip: 2 Attach a copy of the workers' compensation policydeclaration a P �f vh�uul�� �/ P p ge"(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 tl pains and p nalties of perjury that the information provided above is true and correct. Signature: Al; Date: g- /2_2D2.� Phone#: 1 SI/ -- "7214 _'2 J4 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 the debris resulting from the proposed work/demolition to be conducted at 2/6, 4)42/x0i-1414/ 114)9- • Work Address Is to be disposed of at the following location: C/9- V05S 0/S70S79-jam 2/ 0 A ,AMM-N Is Hw' . 6114-• a yo ut4 414 4N j4- . O 2 S 3,1, Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. ,e(A. Signature of Applicant Date Permit No. ____-"..'1 MISTRYAS01 RCORSON ACC)RO CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDYVYY) `--�' I 4/12/2023 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 THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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). PRODUCER CONTACT NAME: J A Corson Insurance Agency PHONE FAX 380 Lowell St (rvc,No,Ext): (781)246-5077 I (NC,No):(781)246-2611 #202A E-MAILDSS: Wakefield, MA 01880 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Graphic Arts Mutual Ins Co 25984 INSURED INSURER B;Norfolk&Dedham Mutual Fire Insurance Company 23965 MISTRY ASSOCIATES INC INSURER C: 315 MAIN ST INSURER D: READING, MA 01867 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED I3ELOW 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 REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYY) IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR 5013959 2/24/2023 2/24/2024 PRDAMAGEES S l Ea RENTED EMIS occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 4,000,000 X POLICY JECT PRO- LOG PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: _ $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY fEa accident) $ ANY AUTO BODILY INJURY(Perperson) $ -OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PER 1OTH- AND EMPLOYERS'LIABILITY YIN WE127918A 5/1/2023 5/1/2024 STATUTE ER 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER an ERJMEn BE EXCLUDED? N/A E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under I1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remark;Schedule,may be attached if more space is required) Workers Compensation renewal of policy term 05/01/22-05101/23 216 Main St/Rte 28,Yarmouth MA 02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE n of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tow Tow Route ACCORDANCE WITH THE POLICY PROVISIONS. 1146South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Constlon Srvisor CS-047686 scpires 12/08/2023 NALIN M MIS RRY 25 BLUE JAY'RD - LYNNFIELD MI�1 01940 ar, ii.. >- Commissioner f;. U67m.D.,,_ NOTE FOR SPORT COURT: \„+- \ 1.TRESPASS OF LIGHT AT THE PROPERTY LINE SHALL NOT EXCEED 0.1 \ \ \ \ FOOT CANDL MA/ \ ♦ 2.PROVIDEVIDE MAXIMUM OF 20 FOOT CANDLE LIGHT ON PLAYING SURFACE. \'?♦ _ ' 3.INSTALL 4 LIGHT POSTS(20'HIGH MAX.)AS SHOWN ON THE PLAN. 1 �r�art \ e ai 16 Mistry Associates,Inc. + S 66k \ ♦ \ a7 R7 — 315 Mon Suer �� _ Reading,MA 01867 so_woi __ e1.m,wao vnx>wi.w.aina O ^ .� 7TT' EXISTING 6.00'HIGH S65`03' It;...' _ PVC WHITE FENCE 'n 55 E--"P"•" N ti / E ail t Cla S. %. �.� x--1 V max_ EXISTING 6.00'HIGH— (- H PVC WHITE FENCE ,..:It ` �� n ,�, e�tp OF'�SS�r SrJ �� ° ggg 9 PARKI , haw.m. t\ 10.00'HIGH--'1 -ra' --- \,;a CHAIN LINK FENCE ! '1 "` �jSLOT 1, MiNry WITH GATE „,, _^^ n� 10'X 1 " O? 2'-0'FROM THE ".� kkk p�27335 P ,1 a' EXISTING FENCE 2., 50.00' 9o,.e GIS 0` iiiii NNWPW v " " GROUND ° !4 10.00'HIGH-/ 1 \��\ w CHAIN LINK FENCE * 2.00 OWNER; N 9 ° WITH GATE \,• 216 Route*28 �� 2'-0'FROM THE sYNx,u c. °O11i1GMTi EXISTING FENCE _ ir I1 5� x.rP t.HuoIGiM OS) -2•.R - - ,va b - ( 226R Ahoud Tr. no1.BER OF POLES H) Faisal 900 WATTLED DAYLIGHT. a $ NNIS PLA a 216 Q GRAVEL A ..a • k ORpUND y =CONCRETE SIDEWALK �, C0� I ` 4 hna EIRSTM04APNg11t.:: 'ar' L; R.^ —.�Prn • r I 1 �,•.va �MRma L it 2424' ,, .yw N. - Od Sunbird&Sunbud Amex Lei ° , 2I6,Route 28 _ 3 YamouN,Massachusetts r near COURT LIGHT. x_`x�--x -- »<Knlaslan AE. 20-FOOT CANDLE MAX x — 67 POLE HEIGHT(20') fix___—x--� nsS,wr SURFACE NUMBER OF POLES(4) °" •', •'G — O 300 WATT LED DAYLIGHT. ',24'N IIISPORT COURT A x BACK SIDE SHIELDED .— T (OLOYOO o _= `- i _____ ___ _ .......... ROUTE 28-(STATE HIGHWAY) _. R \ ______ -— 1 PROPOSED SPORTS COURT LAYOUT Seal*1-=30' Scala 1'4 10' _—_--- a.,I+I