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HomeMy WebLinkAboutBLD-22-006583 , . • BUILDING PERMIT APPLICATION 'r APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE, OCCUPANCY OF, E.C.C' E f t ��,,,; il OR DEMOLISH ANY BJILDING OTHER THAN A ONE OR TWO FAMILY DWEL IN• •�I y DWELLING. Town of Yarmouth Building Department MAY 1 ~" `� l;':' 1146 Route 28 • Yarmoth, MA 02664--1-492 _ Tel: 508-398-2?,31 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT BY :Jtfice Use Only 3 Planning Board Information Assessors Department Information: Permit No.BL 22r( I Date•�� Plan Type Map Lot Permit Fee $ Endorsement Date f 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 Permit Number. I 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 79 WHITE ROCK ROAD YARMOUTH PORT MA, 02675 Zoning District Proposed Use 1.3 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required I Provided Required I Provided Required Provided 1.4 Water Supply(M.(i.L c.40.S 54) 1.5 Flood Zona Information: Comments Public Private Zone: BEE: Section 2 - Property Ownership/Authorized Agent 2.1 Owner of Record: TE KIRKLAND REAL ESTATE LLC 79 WHITE ROCK ROAD YARMOUTH PORT, MA 02675 N &IUBENS I tIN ; � Mailing Address: �y�' , �� 508-362-3798 t► 7, 4 1' y �l� 508-362-3798 t fr► /, ,p -am Si nat r Telephone Telephone �`•"Email Address: I 2.2 Authorized Agent: Name(prints Mailing Address: Signature Telephone Fax Email Address:Section 3 - Construction Services 3.1 used Co truetion Supervisor. Not Applicable . Q4 �y r• ®6 _ //J/I ezt. License Number;s , rhfk/t /'� /Y�j//y//�� C`1.30 a, Expiration D to elephone Email Address: f Q 0 l 11,3 . „A • 't L ' T]4T L ' Tlt3MTFiA( 3C3 0141 1!U!, i • • ... .. III r _ . .. '� \ 3.2 Registered Home Improvement Contractor. Company Name Not Applicable • Address Registration Number 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 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 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 Hama • 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 Hama 1. Person Res ons' le for onstni ton. •t L04 7 •r �� -,� /YIA C2-47)3 Ad ses ig / Teleph e • Section 6 - Description of Proposed Work (check all applicable) New Construction ❑ I (tor multiple family only) No,of Bedrooms ] (for multiple family only) No.of Bathrooms Existing Bldg. [1G� I Repair(s) ❑ I Alterations (i) I Addition ❑ I Accessory Bldg. ❑ Type I Demolition Other Specify: P fY 1 Brief Description of Proposed Work: RENOVATION OF GROUNn FI OUR SPACE TO CREATE 'BUNK SPACE' FOR DAY CAMP PROGRAM. INCLUDES TWO CHANGING ROOMS WITH LOCKERS AND BATHROOMS. Section 7- Use Group and Construction Type Building Use Group (Check as appficapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 18 i] B BUSINESS ❑ ❑ 2A E EDUCATIONAL ❑ ❑ F FACTORY ❑ F-1 ❑ F-2 Q 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-1 ❑ 1-2 Q 1-3 ❑ 38 ❑ M MERCHANTILE ❑ Q R RESIDENTIAL ❑ R-1 ❑ R-2 ® R-3 (] SA S STORAGE ❑ U UTIUTY 0 �1 ❑ s-z Q se ❑ SPECIFY: • M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFv: Complete this section if existing building undergoing renovations; additions and/or change in use.I 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(f 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) I Independent Structural Engineering Structural Peer Review Required Yes . No l SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, .Ic Awn' P- 5.-"1 i. i•' as Owner of the subject property, hereby author el + S -�ti ,�,l • my behalf, ' all m by g permit atters elative to work authorized this buildinto act on application. Signature of 0 er 1 Date • SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION I, S k.4 J 5► -A , 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. • J Print + (/ Signature of er/Agent Dat Section 11 - STIMATED CONSTRUCTION COSTS Item • Estimated Cos"(Dollars)to be completed by permit applicant 1.Building 2 Electrical 3.Plumbing/Gas 4.Mechanical(IiVAC) 5.Fire Protection 6.Total=(1 +2+3+4+5) J7.Total Square Ft(tor now sultanas a additixn) I /c2 a ODD — Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway& Historical Commission approval (if applicable) §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 15 0A. �s- �----- MAY 5, 2022 Sign to of Application Date Permit No. ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY) 12/21/2021 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. IMPORRNN'ANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must 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 NAME: AMSkier Agency,Inc. A.M.Skier Agency PHONE Ext): 570-226-4571;800-245-2666 FAX No): 570-226-1105 209 Main Avenue E-MAIL Hawley, PA 18428 ADDRESS: amskier@amskier.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:pMA Insurance Group 23850 INSURED Wingate Kirkland Operating,LLC INSURER B:Philadelphia Insurance Companies 79 White Rock Road INSURER C: Yarmouth Port,MA 02675 INSURER D: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 INSR WVD POLICY NUMBER LIMITS (MM/DDIYYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 1,000,000 X PREMISES(Ea occurrencel B CLAIMS MADE I X,OCCUR ❑ ❑ PHY220201 MSP 2/1/2022 2/1/2023 MED EXP(Any one person) $ 15,000 PERSONAL AND ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY —PRO- FLOC a JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INURY(Per person) $ ALL AUTOS OWNED AUTOSULED ❑ ❑ $ BODILY INURY(Per accident) HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ Deductible: $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE ❑ ❑ AGGREGATE $ DED RETENTION$ _ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT A OFFICE/MEMBER EXCLUDED? N/A ❑ 2022010291401Y 2/1/2022 2/1/2023 $ 500,000 (Mandatory in NH) E.L.DISEASE-EACH EMPLOYEE $ 500,000 If yes,DESCRIPTION OF OPERATIONS below $ 500,000 be under E.L.DISEASE-POLICY UMIT DESCRIPTION OF OPERATIONS/LOCATIONSNEHILCES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Confirmation of Coverage. CERTIFICATE HOLDER CANCELLATION Wingate Kirkland Operating,LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 79 White Rock Road Yarmouth Port, MA 02675 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE6 44.0.10444: HENRY M.SKIER President © 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Gott od 1 uNi6i- Wet, (fit? Y/11,6, HOt , Z1 IN Iii m 00 $. 62 15 ' 31- bZ �Z 1111 12' 3" rt" az Liu 111111111111111111 c-i c ■ • IA NEI _ A A 4 014 . , • �o0 � 5 loop i,�,z� o�f �"�"PsP� IN. ... 1--r.i7---7 � I 1111 MIMI _111101111114- 1 ---miiiiimiift,-- .1..____, _ i2' 3" rtiJr _ ' nor.. 1 • 1 1 i - , -N,•- ,I,triZ6 ' CI 55.. 6 CI 0 = <, ,) W 4 0,4'47 0 —.4 1:0,4.0Ai .... u) Z •*- 0 (01 40) g I) _ z 0 z ..,.41. = to ...i. ...1 tr:2 'ICI 147/ ...I = f , hill ...11 rn .,. al ' iii tA M —' tv 0 44:1 0 44 .„. 4.... 0 ,..,0 .0... fr-'' .. m - tt ft 41 gli .. . r* (*I ril / * r- .... *oot (1) = 1) fa,) —ft ''/'- '3: 1 4 ''''' et 41-' ', :'''' / Sears, Tim From: Sears, Tim Sent: Tuesday, May 24, 2022 10:02 AM To: 'berardichris@hotmail.com' Cc: 'Sandy Rubenstein'; Slack, Christine Subject: 79 White Rock Rd Chris, I have reviewed your applications for renovations and there are some items needed. 1. Health Department sign off 2. Your CSL is expired �!' Plans showing bathroom fixture layout with dimensions 4. New bathrooms may be required to be accessible? Please have Registered Design Professional provide code requirements Please submit these items for review. This email is considered a written denial of your permit application per Section 105.3.1 of the Massachusetts State Building Code. Section 105.3.2 states in part that "an application fora permit for any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been pursued in good faith" You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100, within 45 days of this notice. Timothy Sears CBO Deputy Building Commissioner Town of Yarmouth 508 .398-223.1 Fxt. 1259 mailto:tsears@varmouth.ma.us 1