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)00 . .• pF•Y.4� BUILDING PERMIT APPLICATION Q �, • . ; 4,,N APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, cI OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. wAT76L Town of-Yarmouth Building Department RECEIVED 1 146 Route 28 • Yarmouth, MA 02664-1492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 - ►AN- 0 4 2023 Pef'S� Office UsseOnfy Planning Board Information Assessors Department Informati n: t lYD--23_D3V(PbDate Plan Type® Mai BtJl16rDING DEPARTMENT • "U __ — ,�'� t►Q,uclPermit Fee $ 6.5 Endorsement Date OD According Datw New Deposit Rec'd. $ Date /PI Plan No. 1.4 Property Dimensions: Net DUj $ 1 ct()C- )26. )Other Lot Area(sf) Frontage(ft) Lot Coverage .0)cs\ This Section for Office Use Only Building Permit Number. Date Issued: • Signature: /- /d—a0 Certificate of Occupancy Building Official • Date• is is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: 1106 Route 28 e Zoning District Proposed Use 1.3 Building Setbacks(ft) • Front Yard Side Yards Rear Yard — Required Provided Required Provided Required Provided 1.4 Water Supply(M.G.L c.40.S 54) 1.5 Flood Zone hif miation: Comments Public Private Zone: _ BFE: • Section 2 - Property Owners hip/Authorized Agent ' 2.1 owns of Record: 750 West Center St West Bridgewater Shaw's Supermarket MA 02379 — Name(grin) Mailing Address: Attached Letter 508-245-3971 Signature Telephone Telephone fnlaii Address: 2.2 Authorized Agent nadine.lynch@shaws.com Vertec Corp • 180 Main St Noth Easton MA 02356 *Ks* (pg.ctIttz . Mailing Address: Virgona Z-1-7'a,: 508-230-2600 ] mvirgona@verteccorp.com Signature Telephone Fax _ Email Address: f Section 3 - Construction Services 3.1 Licensed Construction Supervisor: Not Applicable 0 William Faradie 236 Plain St Norton MA 02766 License Number CS - 054753 Address 508-958-5609 billy@verteccorp.com E iration Date Signature Telephone Email Addres s r5/12/24 Hi Y-t. c arctO i e 3.2 Registered Home Improvement Contractor. Company Name Not Applicable 0 Registration Number Address 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 7x [.. 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 1 r-� Not Applicable C3 Thomas P Scott Name (Registrant): 880 Main St Fifth Floor Waltham MA 02451 Registration Number 16015 Artrtrecc, /2 3 Affidavit Attached 781 -693-7400 Expiration oauirg/3-1 -ItloIJi', Section 5.2 Registered Professional Engineer(s)J Area of Responsibiitty Name Registration NumberAddress Signature Telephone Expiration Date Area of Responsibillty Name Registration Number Address Signature Telephone Expiration Date Area of Responsibility Ham* . Registration Number Address Signature Telephone Expiration Date Area of Responsibility Name Registration Number Address Signature Telephone Expiration Date • Section 5.3 General Contractor Vertec Corp Not Applicable 0 Company Name Person Responsible for Construe tionBilly Faradie 180 Main St North Easton MA 02356 Address 508 230 2600 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.) Repair(s) ❑ Alterations Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: Brief Description of Proposed Work: Interior Renovations to the Existing Supermarket. Work will Include Select Demo, Drywall, Flooring, Acoustical Ceiling, Painting, Misc Finishes, Plumbing, Refrigeration, Electrical, and Supermarket Case/Equipment Installs Section 7- Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type A ASSEMBLY D A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 18 ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL. ❑ 29 F FACTORY ❑ F-I ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ 1-1 ❑ 1-2 ❑ 1-3 0 3B ❑ M MERCHANTILE 4 ❑ R RESIDENTIAL O R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S STORAGE ❑ 5-1 ❑ S-2 ❑ SB ❑ U UTILITY ❑ SPECIFY _ M MIXED USE ❑ SPECIFY: _ S SPECIAL USE ❑ r SPECIFY: Complete this.section if existing building undergoing renovations,additions and/or change in use. Existing Use Group: M Proposed Use Group: M Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area • Building Area Existing(i 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 (7BOCMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No. N . SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Shaw's Supermarket , as Owner of the subject property, Vertec Corp hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Attached Letter Signature of Owner Date SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION Mike Virgona [Vertec Corp] , 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. Mike Virgona • Print name Mike 9"��°°'""""" �,,7; °,� �„� 9/2/22 Virgona Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant ,.Building 55,000 z Eiectimal 15,000 3.Plumbing/Gas 5,000 4.Mechanical(HVAC) 5.Fire Protection 5.Total=(1.2 4 3+4+5) 75,000• 7.Total Square Ft.porn.amens■a i aestionl Check Below Cl. Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) • The Commonwealth of Massachusetts Department of Industrial Accidents Pi) Office of Investigations Lafayette City Center .;/ 2 Avenue de Lafayette, Boston,MA 02111-1750 4 �= wwx.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Vertec Corp Address:180 Main St City/State/Zip:North Easton, MA 02356 Phone #:508-230-2600 Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with 4. ■❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My 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: C & S Insurance Agency Policy#or Self-ins. Lic. #:Key0145863 Expiration Date:1/31/23 Job Site Address: 1108 State Rd City/State/Zip:S Yarmouth, MA 02664 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. d9�A'tgaatibe Vt.t.0 Mike Virgona 2022 m� Signature: Date: 8/26/22 Phone#: 617-230-2600 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10 Board of Health 20 Building Department 3fCity/Town Clerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.❑Other Contact Person: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 M =� WWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):VerteC Corp Address:180 Main St City/State/Zip:North Easton, MA 02356 Phone#:508-230-2600 Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with _ 4. ■❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P tY 9. [' Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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:C & S Insurance Agency Policy#or Self-ins. Lic. #:Key0145863 Expiration Date:1/31/23 Job Site Address: 1108 State Rd City/State/Zip:S Yarmouth, MA 02664 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. aywM vgMd b,Mk.u.,au Mike Virgona3„�a,ar. Signature: Date: 8/26/22 Phone#: 617-230-2600 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Revised 7-2019 Fax (617) 727-7749 www.mass.gov/dia s . . __ Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards . i t C o nst # i'on i sor CS-054753 . .. A... clpires : 05I1212024 ,o ', ( 3. WILLIA M C FARADIE I t • 236 PLAIN Si may ti.li NORTON MA J)2766 :... Iv .,y n n /0- • l.., %sroI•III /•I•1JIQ1 rubc1 `/i4t / 1. %.,/ +-rIiLA-0.1., s . x * k** . 4.:1't `r�,!g i" 1""111 *" t * '" It2,'M,$ 4;4, 4/� �w+.I"'"*„,`""9 w rLlk4! J*M .y,,i g 'F� t `"r ,x.. , ,, °.," t t «• Aar 'v .i ,„ Y�. . } �� "t..'1+F' 2" d iY y. t„, X i. , l.y;.;,w -.$ , •+yX^y S . .. t ` s y .;,t` �, '.. ".�t#t� Y r« �.Y:•Y 2.' raq [ i`. .. , + I ' a .`.; • y . , t•• t e , . 7, ,t r4.`a� 4? ..1 .i.t..'.....i,. 2' ! '{�l .'4 .t • . <, , .y. t star . 8/26/22 Yarmouth Building Dept. 1146 MA-28 South Yarmouth, MA 02664 To Whom It May Concern, Vertec Corp. has been hired as General Contractor for the above referenced project. Shaw's is entering into a contract for Interior Renovations to the Existing Supermarket. We Authorize Vertec Corp to secure the building and other necessary permits to complete this project. Please feel free to contact me should you require any additional information. Sincerely, Nadine Lynch,Sr. Construction Manager Shaw's Supermarkets, Inc. 750 Center Street West Bridgewater, MA Tel. 508.313.4616 • §TOWNaOF.:YARMOUTH 1146 Route 28; South Y'ayrmouth, MA 02664 508-398-223 1.!et4261-Fax 508-398-0836 Office of the Buldng;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 1106 Route 28 Work Address Is to be disposed of oat the following location: Republic Services Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Mike Di91uYu9nME> .e. • DN.<n>Mke Vryma.¢Vene< Cpry,pp, email=mvipmaf.e.tec<wp<om. Virgona. <puogo 8/2/22 Signature of Application Date Permit No. ACCPREP® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/01/2022 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 Lisa Kendrick NAME: C&S Insurance Agency.Inc. PHONE (508)339-2951 FAX ( )508 339-4811 (A/C,No,Ext): (A/C,No): 190 Chauncy St E-MAIL lisak@candsins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Mansfield MA 02048 INSURER A: Carolina Casualty INSURED INSURER B: Vertec Corp INSURER c 180 Main Street INSURER D INSURER E: North Easton MA 02356 INSURER F: COVERAGES CERTIFICATE NUMBER: WC Cert REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY $ AUTOS ONLY AUTOS (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 $ $ WORKERS COMPENSATION v MUTE EMPLOYERS'LIABILITY YIN /� STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE 1,000,000 A OFFICER/MEMBER EXCLUDED? N N/A KEY0145863 01/31/2022 01/31/2023 E.L.EACH ACCIDENT $ (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,l)00,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Initial Construction Control Document To be submitted with the building permit application by a ) Registered Design Professional for work per the 9th edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Shaw's Supermarket#7692—Drive Up and Go modification Date: 8/05/2022 Property Address: 1108 State Road, South Yarmouth MA Project: Check (x)one or both as applicable: New construction XX Existing Construction Project description: Expansion of Drive Up and Go space and minor case/shelving modifications. I Thomas P. Scott MA Registration Number: 6015 Expiration date: 8-31-2023,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: XX Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information,and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet"or %�15��RED Mc; electronic signature and seal: ��' 0�'� s 0 -4 r No.bots a l • NALTHAM Phone number: 781-693-7400 Email: tscott@sga-architects.com r i Building Official Use Only Building Official Name: Permit No.: Date: Note I.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen, provide a description. Version 06 11 2013 The Commonwealth of Massachusetts Department of Industrial Accidents ri) 9 Office of Investigations " re rt) Lafayette City Center mitay_ / 2 Avenue de Lafayette, Boston, MA 02111-1750 ..... wwH.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Vertec Corp Address:180 Main St City/State/Zip:North Easton, MA 02356 Phone #:508-230-2600 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. n I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ['New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My 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: C & S Insurance Agency Policy#or Self-ins. Lic. #:Key0145863 Expiration Date:1/31/23 Job Site Address: 1108 State Rd City/State/Zip:S Yarmouth, MA 02664 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. ggluly stoned by Alike Virgnne Mike Vi rg o n a Date 30333r�3b@33303-0'00�-US 8/2 6/2 2 Signature: Date: Phone#: 617-230-2600 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents _ _ = Office of Investigations el —wwsl � - — Lafayette City Center _Ziii =i/ 2 Avenue de Lafayette, Boston,MA 02111-1750 M ,O.'�� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Vertec Corp Address:180 Main St City/State/Zip:North Easton, MA 02356 Phone #:508-230-2600 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. n I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ['New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp, insurance.* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.17 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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: C & S Insurance Agency Policy#or Self-ins. Lic. #:Key0145863 Expiration Date:1/31/23 Job Site Address: 1108 State Rd City/State/Zip:S Yarmouth, MA 02664 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. Dwally sgned by NY.Argau Mike Virgona n7.:z 1330" "°-�5 8/26/22 Signature: Date: Phone#: 617-230-2600 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5E:Plumbing Inspector 6.0Other Contact Person: Phone#: 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Fax (617) 727-7749 Revised 7-2019 www.mass.gov/dia AC�® DATE(MMIDD YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/01/2022 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 Lisa Kendrick NAME: C&S Insurance Agency,Inc. Pn/C N No,Ext): (508)339-2951 FAX No): (508)339-4811 190 Chauncy St ADDRESS: lisak@candsins.com INSURER(S)AFFORDING COVERAGE NAIC# Mansfield MA 02048 INSURER A: Carolina Casualty INSURED INSURER B: Vertec Corp INSURER C: 180 Main Street INSURER D: INSURER E: North Easton MA 02356 INSURER F: COVERAGES CERTIFICATE NUMBER: WC Cert REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION CF 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, ILT R TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE I $ RENTED CLAIMS-MADE OCCUR PREM SESO(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY PRO- LOC PRODUCTS-COMP/OPAGG S 11 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS- HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ S WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY Y/N 1 000 000 A ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA KEY0145863 01/31/2022 01/31/2023 E.L.EACH ACCIDENT $ , OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Q, ' ki ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • Initial Construction Control Document fi To be submitted with the building permit application by a t�ril t Registered Design Professional it 14 1 a for work per the 9th edition of the s.r 1Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Shaw's Supermarket#7692—Drive Up and Go modification Date: 8/05/2022 Property Address: 1108 State Road, South Yarmouth MA Project: Check(x)one or both as applicable: New construction XX Existing Construction Project description: Expansion of Drive Up and Go space and minor case/shelving modifications. I Thomas P. Scott MA Registration Number: 6015 Expiration date: 8-31-2023,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': XX Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept, shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. " WE&D Vic ' Enter in the space to the right a"wet"or 49 PS P k9.1���� electronic signature and seal: f/e r0� `.4 `8 '~ 141).6016 a to i NA.THAM - /I (., i MA sy Phone number: 781-693-7400 Email: tscott@sga-architects.com I �# l . - ` -- Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen, provide a description. Version 06 11 2013 r 114 ii: 's R1 x rx 't t t •+ t , .. ,t K2 f t ,Nita ! -,e .t 4.F' s.`.„ .. ,,..�6� ", i 'rr i., t°u � Rt j �»i " t,a 'fir, t �. '.. e � ` a 'A. tt'+ t.' t sT *.' 2 1 . ski 40 .'� ryjt j" '"e r¢,1. t^ 'ini., r .zit s .1 z ,' r ay. t S < +L. �+ 4. it t r '"C . x y w • � A t , ,1 a .fit, r m r + 4." . . x.. ,! Ty.4 ,,- 41 a , 4 A i$+ .',ta 1,: :x+ p4 S l" • *;;'fat ti c Cti'l 1.;.fit• ;. i_ 1. a„s. i , 1, x °ii ,t .i ..; - E°r +r•Ora :, t.cs,4 �x} Commonwealth of Massachusetts Division of Occupational L�censure A, .. - Board of Building Reg�lations and Standards , TI ions join SiVOIrviso Y ti • CS-054753 E%pires : 05► 1 i20241.3 WILLIAM C F 1RADIE s -' t 236 PLAIN SI , :' NORTON MA'�2766 , a, r I ,. or 41,,f)I.Lt'd.._1 1`"s vv1.71 . ;s.a;•v; 1cr ,..�!� ^+� i 1. V �► r�..A."h." c; x kr: R k. ttSlli3ai +t#++.t+ 3t 'ti'a`.TS'"'� _ " .1 kw "t :++>^ °r 40* i 1* a i..o , e a. t icy' { �+ as S. •,� ' L" {+ti , e s aw 61, stai* 8/26/22 Yarmouth Building Dept. 1146 MA-28 South Yarmouth, MA 02664 To Whom It May Concern, Vertec Corp. has been hired as General Contractor for the above referenced project. Shaw's is entering into a contract for Interior Renovations to the Existing Supermarket. We Authorize Vertec Corp to secure the building and other necessary permits to complete this project. Please feel free to contact me should you require any additional information. Sincerely, -/r/d, Nadine Lynch,Sr. Construction Manager Shaw's Supermarkets, Inc. 750 Center Street West Bridgewater, MA Tel. 508.313.4616 §TOWN;OF::YARMOUTH 28 1146 Route , South:;Yarmouth, MA 02664 508-398-223(1.te t -1261 Fir 508-398-0836 • Office of tle•: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 1106 Route 28 Work Address Is to be disposed of oat the following location: Republic Services Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Mikepl.mMlike Vi9m;OVertec • CON,a, Vir ona �i�--,��,�rtn�..<.m. 9 °pz,o90 8/2/22 Signature of Application Date Permit No. • 1 • •of•Y,q,te BUILDING PERMIT APPLICATION . APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, • C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. z Town of Yarmouth Building Department `�,��-....•",La' 1146 Route 28 • Yarmouth, MA 02664-149)2 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 Permit No. Permit Fee Office Use Only Planning Board Information Assessors Department Information:Date Plan Type Map for $ Endorsement Date / Recording Date New Deposit Rec'd. $ Date Plan No._ 1.4 Property Dimensions: Net Due $ I Dther_ Lot Area(sf) Frontage(ft) Lot Coverage 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 Property Address: 1.2 Zoning Information: 1106 Route 28 e Zoning District Proposed Use 1.3 Building Setbacks (ft) ' Front Yard 1 Side Yards Rear Yard Required Provided Required I Provided Required I Provided 1.4 Water Supply(1dl.Q.L c.40.S 54) 1.5 Rood Zone information: Comments Public Private Zone. BFE: Section 2 - Property Ownership/Authorized Agent I 2.1 Owner of Record: 750 West Center St West Bridgewater Shaw's Supermarket MA 02379 Name(print) Mailing Address: Attached Letter 508-245-3971 _ J Signature Telephone Telephone Finail Address: 2.2 Authorized Agent: nadine.lynch@shaws.com Vertec Corp • 1180 Main St Noth Easton MA 02356I itiRtn.fpI'Iettr^.;:= Mailing Address: Virgona ZE0,0,„b`;7: (508-230-260(n mvirgona@verteccorp.com Signature Telephone Fax Email Address: I Section 3 - Construction Services 3.1 Licensed Construction Supervisors Not Applicable William Faradie 236 Plain St Norton MA 02766 —. License Number Address CS - 054753 508-958-5609 billy@verteccorp.com . Expiration Date Signature 9 Telephone Email Address: 5%12/24 3.2 Registered Home Improvement Contractor. • Company Name Not Applicable D . Registration Number Address Expiration Date Signature Telephone Section 4- Workers' Compensation Insurance Affidavit (M.G.L c. 152 S 25C (6) Workers Compensation Insurance affidavit mist 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 Ix ... 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 ❑ Thomas P Scott Name (Registrant): 880 Main St Fifth Floor Waltham MA 02451 Registration Number 6015 ArtriresS [A_ffidavit Attached 781-693-7400 Expiration Date8/31/2 3 ,cI JI U m —1 Section 5.2 Registered Professional Engineers) Area of Responsibility Name Address Registration Number Signature Telephone Expiration Date Area of ResponsibilityName Address Registration Number Signature Telephone Expiration Date Area of Responsibility Name Address Registration Number Signature Telephone `Expiration Date 1 Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date (Section 5.3 General Contractor 1 Vf'rt('c Corp Not Applicable ❑ Company Name 'Billy ita( le Person Responsible for Construction 180 Main St North Easton MA 02356 Address 08 230 2f700 J Signature Telephone ' • , Section 6 - Description of Proposed Work (check all applicable) • ' New Construction ❑ (tor multiple family only) No.of Bedrooms (for multiple family only) No.01 Bathrooms Existing Bldg.)a Repair(s) ❑ Alterations Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: Brief Description of Proposed Work: Interior Renovations to the Existing Supermarket. Work will Include Select Demo, Drywall, Flooring, Acoustical Ceiling, Painting, Misc Finishes, Plumbing, Refrigeration, Electrical, and Supermarket Case/Equipment Installs Section 7- Use Group and Construction Typel Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A.-3 ❑ 1A ❑ A 4 ❑ A-5 ❑ le ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL ❑ 2B a F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ INSTITUTIONAL ❑ I-1 ❑ I-2 ❑ I.3 ❑ 39 ❑ M MERCHANTILE 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S STORAGE ❑ s-1 ❑ S-2 ❑ 59 ❑ U UTILITY ❑ SPECIE" M MIXED USE ❑ SPECIE": S SPECIAL USE ❑ SPECIE": Complete this section if existing building undergoing renovations, additions and/or change in use._ Existing Use Group: 1M I Proposed Use Group: FM Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area 1 Building Area Existing(if applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor(st) Total Area All Floors (sf) Total Height (ft) Section 9 - STRUCTURAL PEER REVIEW (7B0CMR 110 11) I Independent Structural Engineering Structural Peer Review Required Yes No. N . SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN DOWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Shaw's Supermarket , as Owner of the subject property, Vertec Corp hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Attached Letter 1 Signature of Owner Date • SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION • Mike Virgona [Vertec Corp] , 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. Mike Virgona Print Name Mike Diqulry :ITIZ t.. o`Ror 9/2/22 Virgonam �w Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant I.building 55,000 2.Electrical [15,000 3.Plumbing/Gas 5,000 4.Mechanical(HVAC) 5.Fire Protection 6.Total=(1+2+3+4+5) 75,000 7.Total Square FL tl ns.smrm+es i atrllbxel Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway E.Historical Commission approval (if applicable)