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Home My WebLink AboutBLD-22-006585 withdrawn 1219-22 jk E C a E. ! - BUILDING PERMIT APPLICATION �,��Pwn ,�-1c -�� . tMAY1 �E APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, ; OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. .-- _ k L Town of iiiikYarnmouth Building Department M.•.TTJ.0 Cr s'. •" I l ffi Route _'1� BUILDING DEP�"` di�1. • Yarmouth, MA 09664--1492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 ��II Office Use Only Planning Board Information Assessors Department Information: d'")-22-)°(°5 te Plan C ��1 Permit N Da Type Map Lot Permit Fee $ Endorsement Date / ��,,0O Recording Date New Deposit Rec'd. $ Date 1.4 Property Dimensions: Plan No. Net Due $ Other Lot Area(sf) Frontage(ft) Lot Coverage This Section for Office Use Only Buildin ermit Number. 1 Date Issued: Signature: Certificate of Occupancy Building Official • Date is Is not required Section 1 - Site Information I 1.1 Property Address: 1.2 Zoning Information: 79 WHITE ROCK ROAD r YARMOUTH PORT MA, 02675 Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards I Rear Yard Required Provided Required I Provided I Required I Provided I 1 1.4 Water Supply(11A.Q.1.-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: • ATE KIRKLAND REAL ESTATE LLC 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 N.,1_ (UBENSILIN — ,�� Mailing Address: �� 508-362-3798 1 1 _ � 508-362-3798 C ( Si not r Telephone Telephone • /Email Address: 2.2 Authorized Agent:I Name (print! Mailing Address: Signature Telephone Fax Email Address: Section 3 - Construction Services I 3.1 LI Construtfon Supervisor: Not Applicable (� 'rzcl c S ,.ic Z 6f Ylift / �_ to L S IAA License Number \ /Ad eL4'1 L /` /` p 77G - 714,3 j;Gn AR.b f c>yel S• Expiration D e '. , ' na ure Tele one Email Address: I 0 l l� /ia ►1 . c r. aC� i jl A :. 1 >4,.1' 3.2 Registered Home Improvement Contractor.I Company Name Not Applicable Address Registration Number Expiration Cate 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 iii Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s) 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 Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor Not Applicable Company me HK( S �� Person Re pons'lle/lor Construction /�� Add �Z( S 3 • tir5 71Ls - {B 3 S a re Telep one • ' Section 6 - Description of Proposed Work (check all applicable)I • New Construction ❑ 1 (tor multiple family only) No, of Bedrooms (for multiple family only) No.of Bathrooms . Existing Bldg. 0 ] Repair(s) ❑ ( Alterations Iy1 Addition ❑ Accessory Bldg. ❑ Type I Demolition Other Specify: P fY: I Brief Description of Proposed Work: RENOVATION LODGE 3 TO ADD PRIVATE BATHROOM FOR STAFF Section 7- Use Group and Construction Type Building Use Group (Check es applicapable) Construction Type A ASSEMBLY ❑ A-t ❑ A-2 ❑ A-3 ❑ to ❑ A-4 ❑ A-5 ❑ t B ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL ❑ za ❑ F FACTORY J (❑ r-t ❑ F-2 ❑ 2C ❑ H HIGH HAZARD I ❑ 3A ❑ I INSTITUTIONAL ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-t ❑ R-2 ® R-3 ❑ 5A ❑ S STORAGE ❑ S-t ❑ S-2 ❑ 58 ❑ U UTILITY SPECIFY: M MIXED USE ❑ SPECIFY`. S SPECIAL USE ❑ SPECIFY: [Complete this section if existing building undergoing renovations;additions and/or change Iri 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 I 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 OWN ERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, iL ir7 � i , as Owner of the subject property, hereby aut ze Cam, S fitG\---- ( i t-t7 to act on my behal , i Il matters relative to work authorized by this building permit application. i 5 I �-1' .Y 7.---- Signature o Owner Date SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION C/ l h({ �� d t , 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. Signe er the pains and penalties of perjury. I � V6 1 , Print H 11/ 1,a 1,2� Signature of Own r/ ent Date Section 11 - E T( ATED CONSTRUCTION COSTS Item • Estimated Cost(Dollars)to be completed by permit applicant 1.Building a Electrical 3.Plumbing/Gas 4,Mechanical(HVAC) 5.Fire Protection I 6.Total=(1 +2+3+4+5) ' 7.Total Square Ft.(tom nvw STLCtrIn&aao;boro) I 0 0 0./ Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway& Historical Commission approval (if applicable) The Commonwealth of Massachusetts —. Department of Industrial Accidents _°=io= 1 Congress Street, Suite 100 yfw Boston,MA 02114-2017 ,;;� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Legibly Name (Business/Organization/Individual): WINGATE KIRKLAND REAL ESTATE LLC Address: 79 WHITE ROCK ROAD City/State/Zip: YARMOUTH PORT, MA 02675 Phone #: 508-362-3798 Are you an employer?Check the appropriate box: Type of project (required): I.O I am a employer with employees(full and/or part-time).' 7. D New construction 2.D I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling • any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. t 9. ❑Demolition ® gy (No workers'comp.insurance required.] 4.{:I am a homeowner and will be hiring contractors to conduct all work on my property. 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.t 1 •❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ AM SKIER Policy#or Self-ins.Lic.#: 2022010291401Y Expiration Date: 02/1/2023 Job Site Address: 79 WHITE ROCK ROAD City/State/Zip: YARMOUTH MA 02675 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 veri cation: I do hereby ce i y uTi..e.r.411ain and penalties of perjury that the information provided above is true and correct. Signature: � Date: MAY 5, 2022 Phone#: 508c382-3798 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. 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 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 Work Address Is to be disposed of oat the following location: YARMOUTH TOWN DUMP Said disposal site shall be a licensed solid waste facility as defined by M.G.L. c.,_Ch. 111 150A. l) �� MAY 5, 2022 1 Date Sign tyre of Application Permit No. � s� c . , �S p �. I{ E '{ti �1��7 4� .E' k d M, .� . 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