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Home My WebLink AboutBLD-23-003687 • • of•Y'q,4, BUILDING PERMIT APPLICATION . �.e 1• APPLICATION ,TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, S ., ��. ' C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. •* R E C \#}±r Town of Yarmouth Building Department 1 l-ifi Route 28 • Yarmouth, MA 02664-4492 . -IA OE 2P23Tel: 508-398-2231 ext. Fax 508-398-0836 - WI- Use Only 3 Piannin)Board Information Assessors Department Information: BUILDIN pa LENT G�. j ate Plan Type n Map Lot �tlttV 0: , Permit Fee $ (150 c- Endorsement Date / Recording Date New Deposit Rec'd. $ (,pi Date Plan No._ 1.4 Property Dimensions: Net Due $ 7 Other_ Lot Area(sf) Frontage(ft) Lot Coverage This Section for Office Use Oniy Building Pem.it Number Data issued: Signature: ; / /c . Certificate of Occupancy. Bitifr3ing Official Date is Is not required Section 1 - Site information i + 1.1 Property Address: 1.2 Zoning Information: f Zoning District Proposed Use 1.3 Building Setbacks (ft) ' ,Ct y '. 5 ,,-3 _ cka_eAlt__ Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.4 Water Supply(M.O.L c.40.S 54) 1.5 Fiood Zone Information: Comments Public Private Zone: _ BFE: Section 2 - Property Ownership/Authorized Agi:nt 2.1 Owner of Record: • Name(print \ 1iY\tY\C ,�}) ��(`r ii Mailing Address: .bat.) (a). 15.05 cto (r-Ar .T) b i( '? M i v ((._, ,t�v 4 ,tC,o co ce(v. Signature Telephone Telephone Email Address: 1 2.2 Authorized Agent: ��('wI1(1 v ‘ ,Y )y '351- 11UVIT) 'Ik- 4 ( i ttit Iii4- N _ t ( , ______ , i Mailing Address: 4, — i Telephone Fax Email Address: .i Section 3 - Construction Services 1 Llcsnsed�Consttruction Supervisor. Not Applicable ❑ 1\i1r\ Hr'iot-l' ,i 1r I li OCI 0 y3 C License Number L\ri ' \ U �I t \._/ .140k' (,i0- 1(u , pAExpiration Date --Sig Telephone Cmlail Address: 7 n 5 , C-o nil 3.2 Registered Home Improvement Contractor C mpany Name cl Not Ap2licable Address Re is ration Number �-, �7 ` �2312O2-9 � 1 [ Expi ation Da e • Telephone • Section 4-Workers'Compensation Insurance Affidavit(M,G.t_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); r Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(sj-1 Name Area of Responsibility Address Registration Number ---- Signature -- Telephone Expiration Data 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 G-CL, eneral Contractor C� ` y.` wcCA(Th Not Applicable CI Company Nam% �wtry vi-cCOLOS t P r n es onsible for onstructio ` ,Addmsc_ r )) , ?s t111 l_iL�l<< / .t(4 g natur Telephone t • ' • - , Section 6 - Description of Proposed Work (check all applicable) • • New Construction 1❑ (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ❑ , Repair(s) 0 1 Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type I Demolition Other Specify: Brief Description of Proposed Work: ,U;« , ci C. ,4 cfrn •fie IDUCA .- 0-- -ham-- 1l; 0, (n Section 7- Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 18 ❑ B BUSINESS (" 2A E E EDUCATIONAL ❑ 2,8 ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3e ❑ M MERCHANTILE ❑ 4 0 R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S STORAGE ❑ S..1 ❑ S-2 ❑ 5B ❑ 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(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) 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 I' ',` -i2- IASSe �S , as Owner of the subject property, hereby authorize LLAMA- s✓t1�CfUG- tArl tDal\C ifiCLt,) &Y\� to act on my behalf, i-ll matters relative to work authorized by this building permit application. v_P`. ,9).4 12.-\21- Q .. Signature of Owner I Date (algeolldde ll) lenOJdde uolsslwwoo IEqualsIH AeMy6IH s6u1i PIO ❑ (eicwoodd }I) 6uliid uolsslwwo0-uotEMasuo0 ❑ ^nola9 )4oeq p psuome9sa»nasauwn �2 U 7d'elenbg rElol'L (5+y+p;+Z+Uale1ol'9 uopalnid eat•s (3 VAH)leolueyoe '7 S /6ulgwnld•g leouhel3 Ln 6u!Pipne't luealldde hulled Aq pataidwa7 eq o3(s.ielloa)lsoa pe3Ewlis3 wall SISCJO NOLLOnaLSNOO a3.1.dwL LS2 - 11 uo goes sled ue6vpeumo ry lg "Z-Z1 tZ(Z /�t (f 1� 5 { \ ewEN juud • •AinEed{o segiEued puE su12d eq .iepun pau6is •Ieljaq puc e8pelmou Atli io peg ayl of 'e eJn a puE erul a uolleolldde 6ulo6Jol ayl uo uoilewJolu!puE sluewe;Els ay;ley es ioep AgoJeq lua6y pazpoylny/JauMo s2 ' 21,•Alsryrilit ,21 n ,1.--.c .1 NOILV1=1V1090 1.1490%,CI3ZIIdOH111y J'd NMQ g01. NOLLOBS The Commonwealth of Massachusetts 1.2 Department oflndustrialAccidents g' 1 Congress Street, Suite 100 et Prr Boston, MA 02114-2017 5�•° www.mass aov/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): Cf--T- ct�a k Gr ( �—tjc.Address:s ;Ju IUf Ace . City/State/Zip: Ytt WA C)2021 Phone #: U1 )3Lci— Are you an employer? Check the appropriate box: Type of project (required): ,`l� 1. am a employer with �V employees(full and/or part-time).* 7. ❑New construction 2.—I am a sole proprietor or partnership and have no employees working for me in g S. Remodeling any capacity. [No workers'comp. insurance required.) 3. I am a homeowner doingall work myself. t 9. C Demolition Cy [No workers'comp.insurance required.] 4.1=1 property.I am a homeowner and will be hiring contractors to conduct all work on myI will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.11 Plumbing repairs or additions 5.1:1 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.1 13.El Roof r�e]pa�irs 6.D We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�ther`" "lC" 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 my employees. Below is the policy and job site information. Insurance Company Name: `--1 ✓ L'llet Policy# or Self-ins.Lic.#: V)( 'S 1 O Expiration Date: ` I lO rZ Job Site Address: 4 IYYWIN_P„.ir City/State/Zip: \0,10(1(A)iY\ 62(t5-7� 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 S1,500.00 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 under the pain dpenalties of perjury that the information provided above is true and correct. Signature: Date: (21 z7/2-z_ Phone#: 19)3ici--/2-2() 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/T'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223[1 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 • LI �,nr.rn�„r �I \ a�rYw 02�-� conducted at � Work Add ss Is to be disposed of oat the following location: WO 1-1 l al k3i/ C7'Clc1anrt Yr* C523=}-o Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. /2 21 Zz i re of Applica ion Date Permit No. • t 4. • . pF'+'AR BUILDING PERMIT APPLICATION ' . .�F 'r, APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, 5�; �,� OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. . R E C ,. :I. ,i Town of Yarmouth Building Department 146 Route `8 • Yarmouth, MA 02664--1492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 JA 0 6 2i'13 • _ E ;IN. Use Only Planning Board Information Assessors Department Information: B U I L D I N ''t Tllli fI' ENT gL t p�j' ate Plan TYPr, Map Lot . Permit Fee $ (®t= '- Endorsement Date f Recording Date New Deposit Rec'd. $ (p0�Date Plan No. 1.4 Property Dimensions: Net Due $ X' Other_ Lot Area(si) Frontage(It) Lot Coverage • This Section for Office Use Only Building Permit Number. Date Issued: Signature: - - 4 . Certificate of Occupancy- Bur g Official Date is Is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: r Zoning District Proposed Use 1.3 Building Setbacks(ft) ' 19 )/ _. •. 5 .a��` �� Front Yard t ll Side✓Yards Rear Yard Required Provided Required Provided Required Provided \J l\P- N \ h\--- N 4 er td\-- 1.4 Water Supply(14.0..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: Name(print Mailing Address: 5A)315-05ctO I 5c1( Signature Telephone Telephone �.Email Address: / 2.2 Authorized Agent I 1_A-4\1\(\ \ '1 , ., 4,'''',)YI 1-4'Vs. -, )50 )uvorke, 4 (4-I' A IA i 'i ;41- Narnf{prinj Mailing Address: t ' v t'{ II,�'; illyI- lL'..2.3 igaatur Telephone Fax Email Address: Section 3 - Construction Services _ 1 LIc\s( d Con nssstruction Supervisor: Not Applicable (] ��// OCI onLk3 SV3� 1;� 0 '\ _ r,t, -r� _ _ License Number A sr, rl I �� l /1 \ 202LI -Tt/ .' , ;,��I`!•-.,--1-)3 )r'i's( (z'(r(:1 1"bl �� ('�i ,�' • Expiration Date —di n Telephone Ty l�maii Address: e-fons . Corill Commonwealth of Massachusetts 8 Division of Occupational Licensure Board of Building Re ulations and Standards Cons ion Stipeirvisor CS-090743 z,• E•;fpires:04/2112024 DAVID ARRgWSMITH 20 WAYSIDEA N CANTON MA12021 e 401.1,t4013` c.� i41-T.•� Commissioner da DCv�t - (10):40 c-) 4r < > 1:1 94. A o 1 IT r. * z - 0 el NI — -' -, -_..:1 •„,,;,,r.,_,-0 a z . - c• CD 44.-0 0 -4 TA > •A'....;',. 8 f rt,., 1,,?,-. m•,., z ,.. O rsi 24 0 CO C rri— =1 6 -. -, 5 :i- 2 P 0 > •-•., O x 5)2 0 U; •• t-7-1 m ii-co $ 2 -,-- x=.-, -•,-,, t '2 _ 001. 7- _ . a3-,,04, z a§t4-1,2 tp ''.e-:' 3 0 ,-- , - Alr ,6 .,,, - \ E,4.e,a 1-•-•, .,--,- \ 61 ,......: mt ... 1 ' — to 2:SI)4 g 1 ....a. ‹ • (Is , 6 <I) C° 3 5" o F :•ki. : 2. > .x, LC rr C , . w o....." C - 2 i I i z 47 A Z tO F. ti• , : V.',-"4 b N.,,,,,--- ,--2...,t ,....,a, IF (1' t. a a As 0 / 0 I i P 1 % 51. I t ` • • dF'Y�9R BUILDING PERMIT APPLICATION . AF 16 APPLICATION ,TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, -e, al C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. R E C sy r Town of Yarmouth Building Department 1146 Route 28 • Yarmouth, til0266-1•4492 Tel: 508-398-2231 ext. Fax 508-398-0836 ' JA OE 2e23 'if1. Use Only Planning Board Information Assessors Department Information: B UILDIN Aui '''V1ENT j' at Plan Type Map Lot Permit Fee $ (60 cC. Endorsement Date f Recording Date New Deposit Rec'd. $ (p0 Date Plan No. 1.4 Property Dimensions: Net Due $ 7 Other_ Lot Area(sf) Frontage(ft) Lot Coverage This Section for Office Use Only Building Permit Number. 7a)te Issued: Signature: - �' / �� Certificate of Occupancy g Official Date is Is not required Section 1 - Site information I 1.1 Property Address: 1.2 Zoning Information: t Zoning District Proposed Use • 1.3 Building Setbacks (ft) • ,Ct `� �. 5 —-.3 ' Front Yard 1 1( Sidel Yards Rear Yard Required Provided Required Provided Required Provided !3 k.\k— t) \ .Pc N ), A. l 1.4 Water Supply(M.Ot.L c.40.S 54) 1.5 Flood Zone Information: Comment= Public Private Zone: BFE: Section 2 - Property Ownership/Authorized Agent 2.1 Owner of Record: • Name(print Mailing Address: ) Signature Tele hone )TS"6_, I l f\,iltettk.)-)ctsck-ky, R.( , ,( r t , p elephone J 2.2 Authorized Agent: Email Address: 1 �� <� i , t��. . 3511 lUiT i� A ( n l i t N t ----—,� Mailing Address: 41,1 (-71%,-t77rtkii L f ,, Telephone Fax Email Address: Section 3 - Construction Services I .1 LIcansed onstruction Supervisors Not Applicable ❑ o, �on Sr3V\/ \L)4 t1 PI t V�l , '' A , license Number `S ' L'' Z1 , 2 2-LI • (',. J Expiration Date _— ignatu Telephone Email Address: ., �. -ycscsa�;rrs,'v-SeoLeN..,.ice,-v.b�ti"..�c�..y.;,d.w.� ..-s::=..x<�x..�..m� �4..::raweas. ;at�s ate.-..:wee;^'�--C d'*Tr`..� ` ..:uv;,�s,;,. �� . co a �►�-■�. aLam..v.nL+•we s}}esnyoossoy� 'y}now�oA . •. �, alyu-iw wile P.M C o •1 I— }ae.1}S JewwnS y p cu.d.ua luRpwwJ 9 I9•r�E=•e - a Q i 'aui 8m}asirop nonoywao3 prydva . , I luaulaaBjdaZI 'pact g f �." € i 3P a } 111 ' I ii ti '°:I i R m C . ObiM, f 11 ��i I Q ZIi sE 11— / MIA Y U! i1 I C4 m M O- o_A iw aye,.a rs I C O yTI O I m w 10 , — J N n 1 Y Us I II p 2 c O., I ram. •O II — Y .am. . Y I II C to 0 ..m. tl rip p p `�1 II o4 �q y $ Y .,1 ,� _o. 1 0 . ! L.�• ! .a m. �1 �+ III__—� _ �� # Oy � ' t s Uy I II I w N .am._I I CV It w m. Ii N I- y„ I TOWN OF YARMOUTH 1146 ROUTE 28,SOUTH YARMOUTH, MA 02664-4451 Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 • 1/616 KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE i APPLICATION FOR 'AHN400 t, 1 CERTIFICATE OF EXEMPTION OW'<INC3 1OhWiVi Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legit*: i 1 P(,) ...,.- , Address of proposed work: II* S Li r)M ER S i j Yh P1°Virj I ;-, i Map(Lot# ila cc I- 13 Owner(s): CH 41-1- 11-f-I--EM1I C PI c LS Phone#: C:7 0 g -3 75 0 Scl 0 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: 130`f, -3 7) , .7,4 Rilj C4 7 11 eo KT, a ). 7 5 Year built: Email: 5 Ckj(a) i n I) ct-L C04:4:2(c cd .CAD i*) Preferred notification method: \z Phone Email PA.i_ft-tti Agent/Contractor: CA ei TA t— CO NI S-77:Zuc-Ttor,i - rzYnN D ;:t.:*;;I t.'Phone#: 7 ii I 7,27 3 si-5 7 Mailing Address: 3 5 9. —14141‘4 PIKE- sr # 30 3 .040 7-0 Al (11,4 C) .)- c-' E.-- Email: Ryan D@ eae ItAC ons. CO i Preferred notification mejhod: Phone Ej Email Description of Proposed Work(Additional pages may be attached if necessary): D ez.C-K Rkeo(i.: fr)Os./T A 7-- (3 fi c K 0 F f 0,0 e Lai-y, 1viot..A.5 1)t-c,-t< HO s- a k g-1.1 Rg.rvi 0 VE0 i)S. ) 1- W A S D ff NI c;Egotts. To ‘,,,I ii 1-44 oN, -11- AP 0% -Y 2 ci_coVATiotsz oN TH 6 ri..44 FIS TH V OTHER ,-,,, s 1 D Es AfizE rxis n66 r)(T-EgioR. r ficivDEs; -1-Hg. RA 4 1.-)t",-1 Er 3 011-1, ("3" 14h-if-IL. ?t-EASf- SEE ATMcF-10) PI-10 /1)5, ci- PLANIS: •I \ it II, Signed(Owner or agent): ' — Date: /-2 5 j -2, 4") --2- 2•-• '.., Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) ,' This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date: Pi SI A> /Approved Approved with change pp.., Amount RO/14) Reason for denial: l'il'C 0 5 LOLL Cash/CK#: C asvl YARMOUTH Rcvd by: 1--"S' P 1)KI"n's 1-1151-.A5L) Date Signed: 121514- Signed:"17- Hirt i*"'" er12 1 i APPLICATION#: .22-C)07 V5.2017