HomeMy WebLinkAboutBLD-23-004810 . z 41 3/�k
• --pF'YA,4 BUILDING PERMIT APPLICATION
3 1z:31Z3
• `tr- APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF,
oC OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
y. Town of Yarmouth Building Department
4^•-....vg 1 146 Route _i • Yarmouth, MA 02664-4492
Tel: 5Q8-398-2231 ext. 1261 Fax 508-39813
t_c E I- V E D
Office Use Only Planning Board Information Assessors Department Inforrr►aYDt1r------------
_07e3r t No.d GIG> ��Date
rPlan Type- may
perm Fee $ Endorsement Date -3 1 /F 7 2023Cr i
; Recording DateBNbWDING DEPARTMENT
Qepo-it Rec'd. $ fis0,e, Date6/ -7 1.4PropertyDimensions:_�� Plan No. .,-_Ci-e I--Ig
t Ue $ + LOther LotArea(sf) Frontage(ft) Lot Coverage� '� This Section for Office Use Only
p, ill,ing Permit Number. Date Issued:
co a;
g -ire: 3 - �_ �3 . Certificate of Occupancy
Building dial Date- is Is not required
Section 1 - Site Information
1.1 Property Address:
1.2 Zoning Information:
N ►N L—IZ 1Z�=�o t�-i `
43,' J Cy1)` y`14/14,0 , r ) 02}3 Zoning District Proposed Use
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required I Provided Required Provided
1.4 Water Supply(1.1.12.L c.40.S 54) 1.5 Flood Zone Information: Comments
Public Private Zone: BFE:
Section 2 - Property Ownership/Authorized Agent
2.1 Owner oqt Record:
-De Y)i pcJ eL c 3 2 -Z.3 W 7catryto f/i 14-
Name(print) Mailirfg Address:
Ect.td____ ( --0.i.) .7-1 -..?-gi-)-- cs-L077-1- 9-se-
Signat Telephone Telephone
Email Address: I
2.2 Authorized Agent:
yam`S )2a- e",... — Sef m c 0✓_e
Name (print) �r Mailing Address:
_is nat re Telephone Fax Email Address
Section 3 - Construction Services
3.1 Licensed Construction Supervisor. Not Applicable D
e Jt).o S Fr? >r g'L
1 �+v License Number
A dre0 l r h i- ) o D 401 , o,XQ.�,+/Vl a tk 41M,4o2i� S — 1041
ss
2),23 s-92 C*,,:60CAi2.OR-100 ( - l ,Expiration ate
Telephone Email Address: z 2023 l
f•
3.2 Registered Home Improvement Contractor.
Company Nam Not Applicable D
F
Regis u b
clAd ss
So a 31 Expiration D=te
re Telephone 0!/r1/�5
ection 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:
_ _S 1/ : 6 G _. eA Not Applicable ❑
Name (Registran GZ�I G✓ `;
ZSe Registration Number-p 3 -
Address
Expiration Date
Signature Telephone
Section 5.2 Registered Professional Engineer(s)
Nam* 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
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 ❑ f (for multiple family only) No.o`Bedrooms (for multiple family only) No.of Bathrooms
•
Existing Bldg. ❑ l Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
P fY:
Brief Description of Proposed Work:
° I Psi l�� '7 Qi s%4
C171,fyi.7
l el s ✓�
Section 7- Use Group and Construction Type I
Building Use Group (Check as applicapable) Construction Type
A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑
A-4 ❑ A-5 ❑ 1 B ❑
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ 2B ❑
F FACTORY
❑ F-1 ❑ F-2 ❑ _ 2C ❑
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL ❑ I-I ❑ 1-2 ❑ 1-3 ❑ 38 ❑
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S STORAGE ❑ S-1 ❑ 8-2 ❑ s8 ❑
U UTILITY ❑
SPECIFY:
M MIXED USE ❑
SPECIFY:
S SPECIAL USE ❑
SPECIFY:
Complete this section if existing building undergoing renovations;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) 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 (7130CMR 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
, as Owner of the subject property,
hereby authorize .Gt1'' O5 4-7,} ,ttJ d D4 to act on
my behalf, in all matters relative to work authdrized by this building permit application.
Signatur I Owner Date
SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION •
I, Yl I S � as Owner/Authorized Agent
hereby declare that the st tements 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 Narici?
2-/), 2-3
Signatur f Owner/Agent at
9 e
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
# V-00 " °
2.Electrical
3.Plumbing/Gas
4.Mechanical(HVAC)
5.Fire Protection
6.Total=(1 +2+3+4+5) $ cpO0'a10
7.Total Square Ft.(tor new stcnnes a addibora)
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
•
The Commonwealth of Massachusetts
1-4=_ Department oflndustrialAccidents
sirI Congress Street, Suite 100
\��� 4 Boston, MA 02114-2017
tIti5�•`'�� www.mass.gov/dia
N. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): p
Address: Zu 6.10
Y c� f
City/State/Zip: SAvvvta,,fir Phone #: S oe 3.7 rj 5 y'y
Are you an employer? Check the appt<opriate box:
Type of project (required):
1.❑I am a employer with employees(full and/or part-time).*
7. El New construction
2.4I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers'comp. insurance required.] 8. [Remodeling
3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑ Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on m property.Y I will 10 El 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./ 13• Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
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.
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 nzy employees. Below is the policy and job site
information.
Insurance Company Name: i Gth.� p.�� C U,1716-e (ViA4.1)0
Policy#or Self-ins. Lic. #: (J 2 1/C C A-- /l 4-fJ g Expiration Date: 03/1 2
Job Site Address: ' ZQ} �{� .�M2u Af _G�_3 City/State/Zip:C) • 144 U /��" ----
Attach a copy of the orkers' compensati policy declaration page(showing the policy num ed 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 uncle he pains and penalties of perjury that the information provided above is true and correct.
Si nature: z g
Date:
Phone#: \a 5 (/& 3 5 q
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 , YVV' -i 7-
Work Address �T
Is to be disposed of at the following location: T'D( Y\ p jc,L4,vvot,9"k
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
- Dittj'al- 2-A--)--A0
Signature of Applicant Date
Permit No.
U
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 burn 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. 4 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
1
' ^
(Policy Provisions: VVC000000C)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: Hartford Casualty insurance Company
ONE HARTFORD PLAZA HARTFORDCTO8155
THE
1P���l�
�����~� � �'���'
NCC| Company Number: 14387 .
Company Code; 3
Suffix
LARn nsmsmmL
\ |
POLICY NUMBER: 02VVECAK4HJ8 | 3 |
Previous Policy Number: 02VVECAK4HJ8
1. Named Insured and Mailing Address: MAAGAYATR| MARINER, LLC
(No., Street, Town, State' Zip Code) 573 ROUTE 28
WEST YARK8OUTHKUA02G73
FEiNNunnbar: 474265766
State Identification Number(o):
The Named Insured is: LLC
Business mf Named Insured, Hotels(except Casino Hotels)and Motels
Other workplaces not shown above: S73 ROUTE 28
WEST YARyNOUTHMAU2673
2 policy From 03/01/23 To O301/24 ANNUAL
' 12:01am, Standard�imeek the inounad's mailing address.
Producer's Name: JJG|LMART\N AND SON AGENCY INC
12Q3 POST ROAD
VVARVNCKR| U2V88
Producer's Code: 02090168
Issuing Office: THE HARTFORD BUSINESS SERV|CECENTER
3800VV|SEN1AN8LVD
SANANTON|OTX78251
(806)467-8730
Total Estimated Annual Premium: $2 627
Deposit Premium:
Policy Minimum Premium: $288K8A(includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment �tTmrm� Fu|| Pay(1O0Y6Dmwn)
The policy is 'not binding unless countersigned by our authorized representative,
Countersigned by ( mu��� mc��'=^� ' O1/3U/23
Authorized Representative Dote
Pagel (Condnuedonne��page)
Form�N���8��1 � ��> Printed in U.S.A. �xp\ra��on Qa�e� O301/24
Process Date: 01/20/23
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3/13/23,8:39 AM Mail-Sears,Tim-Outlook
573 Route 28
Sears, Tim <tsears@yarmouth.ma.us>
Mon 3/13/2023 8:39 AM
To:Carlos Figueiroa <Chfigueiroa2002@hotmail.com>
Carlos,
I have reviewed your application and there are some items needed.
Health Department sign off
12(Water Department sign off
Please submit these items for review
Timothy Sears CB0
Deputy Building Commissioner
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsearsfyarmouth.ma.us
https://outlook.office.com/mail/sentitems/id/AAQkADE3MDQ5NWZmLTkOYzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQAPYB97ZtGgJAkTWWTxc... 1/1
°v_re' " TOWN OF YARMOUTH
o c' HEALTH DEPARTMENT
;�r' `� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: c 7-5 ) /<?/7 ? , &7 ,y,z,b jto - 7r.7)/1--- 2h 73
Proposed Improvement: ,f-P ,/j:, C Yv.:,/2�t/ �� I)ka - )
. . 7iG/7` . , -l:/�G'-✓yf 7il' r i/�' /Y‹ nt G`1-
zry?e1 / ,)' o G/C� //G / /'7 L
Applicant: /l kin 6l Lt /7- / `1/(6 i i"1P't Tel.No.: / -0
Address: 7 _, /7r 21 l o , . 1l'/�,GL?'I(i 1 ),1 6 -3 Date Filed: /7O/2O/ 2_3
**!f you would like e-mail notiftcation of sign off please provide e-mail address:
Owner Name: 1 G(tzV (1 ' /
Owner Address: — Ca)1 )C 7�--S
A-h6 t" e - Owner Tel. No.:(771i))j7 6 2/5-7
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e.,Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(l.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed)—
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY, 0,,. C r DATE: 3-�0 r-.A3
COMMENTS/CONDITIONS: PLEASE NOTE
TOWN OF YARMOt1TII
of7Y`' 4,r
Io WATER DEPARTMENT
O^.(`'�( ' y 99 Buck Island Road
tk• �An AV West Yarmouth, MA 02673
�' '�"„ `,27 Telephone: (508) 771-7921 • Fax: (508) 771-7998
BUILDING PERMIT APPLICATION FOR
WATER DEPARTMENT SIGN OFF
TRANSMITTAL FORM
BUILDING SITE LOCATION: 73 ) gpt,Lt .2q, wphAteuift,1 ►r --OZ6 -3
PROPOSED WORK: Q CCOy
APPLICANT: 4
ADDRESS: . ' C , 7'awju)(-1 rWArle ( _
TELPHONE: C 7 7 if •-0 Alf
- GcJ 1 gave�,us yi 'c Cd
c /
E TyRESIDENTIAL AND/OR -OMMERCIAL BUILDING M
ilt
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
Safety, Property Protections, i.e. Smoke Detectors, Sprinkler Systems,etc
0 •
API 1 , IGNATI`RI. D. TE
OFFI E dSE: COMMENTS ON PERMIT APPROVAL OR DENIAL
•
RE I WED BY WATER DIVISION(SIGNATURE) DATE
SERVICE NO. 1 3 O i/ 3 0
NAME M P.I Nen M 0Te
STREET I ouTe 2 p-
VILLAGE Ws `/ /1,/t 6v/ -1
METER NO. 33 D 3 r9 3 9 ca," I�NI �"oL o .-7 y
rsr
City,• MitItIw rlr,
at IV 4 4
c.
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111.1771
• IT"( �/N pf
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Asti
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SERVICE NO. J30a.0 -30
NAME M RR uyeit M A�e L
STREET (ROUT. .F
VILLAGE Wil \/I+ M 0 l,/T1/I
METER NO. 33 03 293 ,2'' ..lo-i-y
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A
GE RAFTER BEAMMA
2X8 CEILING JOIST I
CONNECTOR 1 %" GYP. BD. PLUS
3HETHING PLUS, 8" FIBERGLASS INSULATION
_E ROOF
RFTER MATCH ;�i- -
WITH EXISTING / .
`o NEW 4X8
BEAM BEAM - -
♦`♦••♦♦. t„
;EILING
j A I _ _
I
UBE _ Eo
LOW ---r1 - —
JND I
I 1:87
I SECTION AT "AA" ,� 0
SCALE: 3/8"=1 '-p" `-.--N- _ _ --
NOTES:
N1. THE PR
ENLARI
FINISHI
2. ALL WC
IN DESK 3. DISPOS
WITH S'
4. PROTEC