HomeMy WebLinkAboutbld-23-004415 .'OV•YAR BUILDING PERMIT APPLICATION
APPLICATION TO CONSTRJGT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF,
0 _� OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
y Town of lirmouth Building TT.C„«, �'�` Department
16�?�•' �' I I-f(i Route 28 • Yarmouth, MA U2(i6-I- 492
Tel: 5Q8�-398-2231 ext. 1261 Fax 508-398-0836
i.,1°1. ( Office Use Only
OW 7 Planning Board Information Assessors Department Information:
lit
Permit Note Plan Type Map Lot
Permit Fee $ Endorsement Date /
Recording Da-e New
Deposit Rec'd. $ Ott)CI) Date 1.4 Property Dimensions:
Plan No.
Net Due $ d other
Lot Area(sf) Frontage((t) Lot Coverage
lc
This Section for Office Use Onty
Building Permit Number. I Date Issued:
Signature: / ' - - y 'd,3 Certificate of Occupancy
Building Official • Date is Is not required
1 Section 1 - Site Information I
1.1 Property Address:
1.2 Zoning Information:
', MP\
Zoning District Proposed Use
1.3 Building Setbacks(ft)
Front Yard Side Yards i
I Rear Yard
Required I Provided Required I Provided I Required Provided
1.4 Water Supply(u.a.t_c.40.S 54) 1.5 Rood Zona Information: Comments
4' Public Private Zone: SEE:
Sect on 2 - Property Ownership/Authorized Agent
2. wner of Record:
SC._1bur 1L1oldskn(is-) LLC- _ c, 4- k\- zr < LJ. t„....-A.,AM-
k N (print) Mailing Address: M pr 0 7..�-7 3
.. 7/ Giev ee .s7f -/V7/.-a/e)&0
Si at re Telephone Telephone Email Address: /
2.2 Authorized Agent:1
Name (print) Mailing Address:
ili
Signature Telephone Fax
Email Address: !
Section 3 - Construction Services 1
3.1 Licensed Construction Supervisor. Not Applicable D
/ -
c .% i54z.
A / p License(A7nQ
Number i
A O (1 ee.a ' lithA`�w - (41. b/OJU,,(J--1 /1/4 �� )
1 Expirat
ion(late
Signature To.e,ohonfk,})2. 0 )D Email Address: - •��(�, bj(1.; LIOC 0.-, - c t> vt
.,
3.2 Reg tered Home Improvement Contractor.]
Company ' ame Not Applicable ❑
' Address Registration Number
1
l expiration Date
Signature Telephone
Section 4- Workers' ►umpensation Insurance Affidavit (M.G.L c. t52 S 25C (6)
Workers Compensation surance affidavit mus: be completed and submitted with this application. Failure
to provide this affidavit will esult 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
I to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c_f. of enclosed space) i
Section 5.- Registered Architect
Not Applicable D
Name (Registran :
Registration Number
Address
Expiration Date
Signature elephone
Section 5.2 Registered Pro -ssional Engineer(sil a
i
Name \ Area of Responsitnlity
Address Registration Number
Signature '-elephone Expiration Date
0,
Name Area of Responsibility
Address Registration Number
0 Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
k Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor
c` , % .GA.) . .W . NC,. Not Applicable D
Company Name
01
Person Responsible for Con t nj (`dG t ,4 t y
i A
Si ature
C " 1 / d Telephone
' • , Section 6 - Description of Proposed Work (check all applicable)]
New Construction ❑ (for multiple family only) No.of Bedrooms 1 (for multiple family only) No.of Bathrooms
. Existing Bldg. D Repair(s) Alterations
j 1 ❑ I Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
I
P fy.
IBrief Description of Proposed Work: 11
CSC. ` ,r,.c".L C" %._ C- .�� e. ...-0
Section 7- Use Group and Construction Type I
Building Use Group(Check as Etpplicapable) Construction Type
A ASSEMBLY ❑ Al ❑
A-2 ❑ A-3 ❑ to ❑
A-4 ❑ A-S ❑ le
B BUSINESS
2A ❑
E EDUCATIONAL ❑ ❑
F FACTORY ❑
F-I ❑ F-2 ❑ 2C ❑
H HIGH HAZARD I ❑
l 3A ❑
I INSTITUTIONAL ❑ I ❑
I-2 ❑ I-3 ❑ 39 ❑
M MERCHANTILE ❑
R RESIDENTIAL ❑ R ❑ R 4 [IS STORAGE -2 ❑ R-3 (❑ 5A ❑
0 s' CDs-2 ❑ 59 ❑
U UTILITY
SPECIFY: _
M MIXED USE ❑
SPECIFY:
S SPECIAL USE ❑
SPECIFY_
!Complete this section if existing building undergoing renovations,additions and/or change in
g use.
Use Group: !r.jc Proposed Use Group: C g1
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
O Section 8 Building Height and Area
Building Area Existing(f applicable) Proposed
Number of floors or stories
include basement levels 1
0 Floor Area per Floor(sf)
Total Area All Floors (sf)
Total Height (ft)
Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes No j
SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN !
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, V �' ( UCI la--- , as Owner of the subject property,
0' her authorizeq__-)k("-- .-3 1 r` `"`' (�
-� to act on
my alf, in all matters relati to work a horized by this building permit application.
--9-7c
Date
Sign r of Owner
I SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION
(?) /\ C 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 tj r, Q 3
Print/�J \
Signricil
•
re f wrier
ZL 1-
1(\
ent Date
!Section 11 - ESTIMATED CO UCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
57,cc&>
2.Electrical
3.Plumbing/Gas
4.Mechanical(HVAC)
5.Fire Protection
6.Total=(1 +2+3+4+5)
* 7.Total Souare FL Itx new smtuces&addtbea) S 7,L L,v
Check Below
❑ Conservation-Commission Fling
(if applicable)
❑ Old Kings Highway& Historical
• Commission approval
(if applicable)
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