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HomeMy WebLinkAboutbld-23-004147 RECF ! V' ED pLit lei 0-3. ', . BUILDING PERMIT APPLICATION „Jo 2 6 ,(;' ° APPLICATION TO CONSTRUCT REPAIR, RENOVATE CHANGE THE USE, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLLING.ANCY OF, BUILDING DE t ;,„L*. 4 Town of Yarmouth Building Department By — �" ^--M'1 1 14fi Route 28 • Yarmouth, MA 0966.4-4492 (S(7' 1° Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 - CQ rir Office Use On Planning Board Information Assessors Department Information: J PermN-.7 -0/Nikli J Plan Type YPe_ Map Lot Permit Fee $7o�7 Endorsement Date / V� Recording Date New � • Deposit Rec'd. OP ----'Date plan No. 1.4 Property Dimensions: �� Net Due $ 19 Other �� Lot Area(st) Frontage(It) Lot Coverage 0 la Lit, ii This Section for Office Use Only Building Permit Number! Date issued: Signature: ��— Certificate of Occupancy Building Official • Date is Is not required Section 1 - Site Information 1 1.1 Property Address: 1.2 Zoning Information /iy 5,77.41 /Sf/ w/a/ !3'cp *1.,._ Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Required � Rear Yard q Provided Required 1 Provided Required 1 Provided 1.4 Water Supply(M.Q.L c.40.S 54) 1.5 Flood Zone information: Comments Public Private Zone: _ BFE • Section 2 - Property Ownership/Authorized Agent 2.1 Owner of Record: lit G.l'A. V t , l/V ,ST7>r410/3/1 li Name ienntlt ' Mailing Address: Signature Telephone Telephone Email Address: / 2.2 Authorized Agent I /24 E,I-I/e— r 40-64-0-i` -Fh`. di 7a AMIAJ -. s• e f7 07-41 Name I I Mailing Address: �cyf—�5 77 ('�9fI� c�I c�rQ �lC u .� At rue �9 c' ,ti4,te gnature Telephone Fax Email Address Section 3 - Construction Services 1 3.1 Licensed Construction Supervisor. Not Applicable D nik i7/( 5, i#04A'' • / i L'" ie e' '4 0.5._30 License Number Address ' e z I ^ 454 S.--r D -`7 73 NtAK RA6iiiiiod; i,,xzi,u, Expiration Date Signature Telephone Email Address: /t:4,11 514? 42y {z_cx_e a a_.bcA is ld i vA9 re wood 1 (' nor . C ri 3.2 Registered Home Improvement Contractor: Company Name . Not Applicable ❑ Address Registration Number •)5 7 G /q/.41 I. S.6.H097MMr1M e 94 5% 7- E:.•oiration Date Signature 41 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 t/ 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 Q Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(sj M i(2 ft�[.6 C a O/L1) P' C, Hams Area of Res onsibliry ;� S C �s'�ve��J I-ti. (v 7 vi /44 An y'77 Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name 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 ❑ Company Hams Person Responsible for Construction Address 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. 2 Repair(s) ® Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: P fy: Brief Description of Proposed Work: NPR W je j,i f' j2' S73 -f- gel ; mu ,,cro b /Nc., i C u. F i 7l3rJt a ,5A "&n c:.-rAv6;i CZ"x-i'i:sc , Section 7- Use Group and Construction Type 1 Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ ❑ A-t ❑ A'2 ❑ A'3 ❑ IA B BUSINESS ❑ A-4 ❑ A-5 ❑ lB ❑ 2A ❑ E EDUCATIONAL ❑ 2B ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-1 ❑ ❑ 1'2 ❑ I'3 ❑ 3B M MERCHANTILE ❑ ❑ 4 R RESIDENTIAL I ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S STORAGE U UTILITY CI s-' ❑ S-2 ❑ se CI SPECIFY: - M MIXED USE ❑ SPECIFY: _ S SPECIAL USE ❑ SPECIFY_ _ Complete this sectionif existing building undergoing renovations,additions and/or change In use.1 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) 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 (780CMR 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 7 45* 77 &7r'S , as Owner of the subject property, hereby authorize f fig' G1 M1-f ,- 4e-,,f/1.!gZ/4)4 to act on my behalf, in all rel tive to work authorized by this building permit,application. Date Signature of Owner SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION ?nat.- eMte.. 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. ?4(AL 4Litil e Print Name 7 . //d.SX)) Signa of Oar/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Rem • Estimated Cost(Dollars)to be completed by permit applicant 1.Building pc,i kt j2G11-40,CP, 3 y; Sly, -- a Electrical 3.Plumbing/Gas 4.Mechanical(tiVAC) 5.Fire Protection 6.Total=(1 +2+3+4+5) 34i 57,' i 7.Total Square FL ON no.smimne,a additive) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway& Historical Commission approval (if applicable) §TOWN O F YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext. 11261 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 //1/ 5779/v)/S N l4.s fi Y IL,D _ Work Address Is to be disposed of oat the following location: CH/V/14 , 6--C/&/A' 6-7, Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. (4_________ /7 ///9d/r)..)- Snature of Application Date Permit No. The Commonwealth of Massachusetts Department of Industrial Accidents . 111 i:—e Office of Investigations _ 1' 600 Washington Street ‘, Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A&A Building and Remodeling Inc Address: 2570 Main st City/State/Zip: South Chatham, MA 02659 Phone#: 5083480065 Are you an employer? Check the appropriate box: Type of project(required): 1129 am a employer with 22 4. El I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. [Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp.insurance.t required.] 5. El We arc a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.EIRoof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other renovations comp. insurance required.] *Any applicant that checks box#1 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 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: A/S/O E- /,16 4 ,4,41(..7g" Policy#or Self-ins. Lic.#: ere--4oe,—94c) ors-pewit Expiration Date: /l/ea-Y Job Site Address: "/ S779/v'-Ar Sfr ttifY City/State/Zip:armouth,MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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. Signature: 42.Z c5 „-of, Date: 8/19/22 Phone#: 508-280-7913 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#: ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYYj �....--� 01/25/2023 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 Christian Barber,CIC The Oceanside Insurance Group PHONE (508)398-2282 FAX (506)760-2211 (A/C,No,Ezth (A/C,No): E-MAIL ADDRESS: PO t3ox 38 INSURER(S)AFFORDING COVERAGE NAIC a West Dennis MA 02670 _ INSURER A, Arbella Protection Insurance Company INSURED INSURER B: New Hampshire Employers Insurance Co. 524126 A&A Building&Remodeling,Inc. INSURER C: 2570 Main St INSURER D: INSURER E: South Chatham MA 02659 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2311709452 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEV 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD wvp POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) UNITS X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A 8500072710 03/09/2022 03/09/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER_ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWTOS NEDONLY X ASCUTOSHEDULED 1020115894 01 03/09/2022 03/09/2023 BODILY INJURY(Per accident) $ AU X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ PIP-Basic $ 8,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE 4620116470 03/09/2022 03/09/2023 AGGREGATE $ DED X RETENTION$ 5,000 $ WORKERS COMPENSATION PER \/I 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE /y ER B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? Y N/A ECC-600-4001098-2023A 01/18/2023 01/18/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsement of the policy. Nothing contained in the certificate of insurance shalt be deemed to have altered,waived,or extended the coverage provided by the policy provisions. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This is to certify that the policies of insurance listed have been issued to the insured named above. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28 AUTHORIZED REPRESENTATIVE et:Zile__Yarmouth MA 02664 — I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards I T�t. I, Cons ion Sliflie7rvisor CS -113133 ,s, ., spires: 05/29/2024 4. ARTAK SAH YAN A -� 180 EBENEZIER ROA `' i , ols _.x O S TE RV I L L 11A 0 ��, it .,� eft . ,. 3 d �ry:'b `, - .raj p � A} .r * S' .6`m a.row�a "4 �, +. 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