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Home My WebLink AboutBLD-23-005481 , • , -oi•-'HR BUILDING PERMIT APPLICATION .O. '$• APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, _ '_C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. y Town of Yarmouth Building Department \+Y_Ttrc crs �.,,�„„.r 1146 Route `_''i • Yarmouth, MA 02664-4492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 Office Use Only Planning Board Information Assessors Department Information: 'Permit NO': p h s� Date Plan Type • Map Lot Permit Fee $ D.O(.) Endorsement Date f v L Recording Date New Deposit Rec'd. $ �Jt(J,t;� Date �y7f% 1.4 Property Dimensions: Plan No. Net Due $ -- Other Lot Area(si) Frontage(ft) Lot Coverage This Section for Office Use Only Building Permit Number. Date Issued: Signature: � A / y. _Z Certificate of Occupancy B din. ..',1Date is i,rot ,oy„i,'`{� Section 1 - Site Information R V 1.1 Property Address: 1 ) o0 1�a, t S-VeG- t X1-4 g' 1.2 Zoning Inform do APR 03 2023 Zoning Dist ictuILDING uPF dtITSe By: - --T 1.3 Building Setbacks (ft) Front Yard Side Yards 1 Rear Yard Required Provided Required 1 Provided Required Provided 1.4 Water Supply(M.Q_L c.40.S 54) 1.5 Flood Zone Information: Comments Public Private Zone: _ BEE i Section 2 - Property Ownership/Authorized Agent 2.1 Owner of\Record: �� Q� �1 l. � `Y-6 1, Dv /C..- O�V 6.L��J Gl Name (print) Mailing Address: D� V C�.�(o�� Signature Telephone Telephone I Email Address: 2.2 Authorized Agent:1 (,,,yk-,R• t / 04,Se.& Name( rintl Mailing Address: ' st a i ii 9 3ss . Signature Telephone Fax Email Address Section 3 - Construction Services • 3.1 Ltcs) .d Construction u rvisor: Not Applicable ID (,) �_ ) vcAt ic( Rc.eAr.).&-(?)c ot License Number r1 1 Lf Addr2t2,7 (.. Weitsi V 8 Ll 5 3 sS `1 i iNc Cj Expiration to Signature Telephone Mail Address: 7c), c4 COMMERCIAL ONLY- BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: 2C0 RCA )Y 2 / j \/ tucr -- Scope of Proposed Work: —ree)1Q do 0 Sy' c, r e Date: L//3 f -5 Based on the scope of work described above, the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept. —508-398-2231 ext. 1241 Conservation —508-398-2231 ext. 1288 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept. —508-398-2231 ext. 1250 Fire Dept.— Kevin Huck/Scott Smith, 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement. n J Applicant's Signature (-)1 '446 I/3/ot g Date Rev. Jan. 2019 • • , Section 6 - Description of Proposed Work(check all applicable)1 • New Construction ❑ 1 (for multiple family only) No.of Bedrooms 1 (for multiple family only) No.of Bathrooms Existing Bldg. ❑ 1 Repair(s) 0 I Alterations ❑ Addition ❑ i f Accessory Bldg. ❑ Type Specify: Demolition Other SP fY: 1 Brief Description of Pro osed Work: Section 7- Use Group and Construction Type I l ' Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A_1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1 B ❑ B BUSINESS ❑ 2A E EDUCATIONAL ❑ 28 ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-I ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M fuSERCHANTILE ❑ ❑ _ 4 R RESIDENTIAL ❑ R-1 ❑ 9-2 ❑ R_3 ❑ 5A S STORAGE ❑ S-I ❑ S-2 ❑ 5B ❑ U UTILITY ❑ SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this section if existing building undergoing renovations; additions and/or change id 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 1 • Building Area Existing(ii 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 (7i3OCMR 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 I, TD°L) LaACl , as Owner of the subject property, hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. q....3-c22:, Signature of Owner Date 3.2 Registered Home Improvement Contractor. , Company Ham. Not Applicable 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 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 ❑ Hams (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s) Hams Area of Responsibility Address Registration Number Signature Telephone Expiration Date Hams Area of Responsibility Address Registration Number Signature Telephone Expiration Date Hama 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 Not Applicable D Company Hame Person Responsible for Construction Address Signature Telephone JThe Commonwealth of Massachusetts 1—,,,,z,iiii,—..11' Department of Industrial Accidents •.. Tiro1 Congress Street, Suite 100 Ayr • Boston, MA 02114-2017 ,.„. www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 4 -le &l l Address: 6 ,c . 141 V'd f . City/State/Zip: .JY S 044 O I Phone #: . O 8 c, 8 4 6/3 s---3- Are you an employer? Check the appropriate box: Type of project(required): in I am a employer with employees(full and/or part-time).* 7. New construction 2.KI am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers'comp. insurance required.] 5 3. I am a homeowner doingall work myself. t 4. ❑ Demolition ❑ y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on m YP property.e 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 5.0 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? 13•El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other .�r ,�61 152,§1(4),and we have no employees.[No workers'comp.insurance required.] V , *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. tContractors 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u 'er the pains and penalties of perjury that the information provided above ' true and correct. Signature: 41 0 . Date: ill3 /d- 3 8 1 Phone#: V �l 4 1 J 3 cc - Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION , as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building Z Electriat 3.Plumbing/Gas 4.Mechanical(I-1VAC) 5.Fire Protection 6.Total=(1 +2+3+4+5) 7.Total Square FL liar new smctnm a additions) Check Below ❑ Conservation-Commission Rfing (if applicable) ❑ Old Kings Highway& Historical Commission approval (if applicable) • Commonwealth of Massachusetts THE COMMONWEALTH OF MASSACHUSETTS Division of Professional Ucensure Office of Consumer Affairs&Business Regulation ) Board of Building Regulations and Standards TYPE:Individual HOME IMPROVEMENT CONTRACTOR 1 Conslirtott- helf$'upervisor Registration Expiration 189692 11/14/2023 CS 103494 Expires: 09105/2023 GARY KASER GARY J KASER,JR ,..; 65 WALKER ROAD BREWSTER MA 02631 GARY KASER tY)Kw 1:11��` 65 WALKER ROAD CG.i 4 BREWSTER,MA 02631 ., Undersecretary Commissioner dice r. reynLfla §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223!1 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 /a00 :S Work Address Is to be disposed of oat the following location: WCW f 0 T . 6c5A Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. gi3b12 Signature of A placation Date Permit No. • • 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 bum 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