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HomeMy WebLinkAboutBLDC-23-2 (2) T r g COMMERCIAL ONLY-BULDING PERMIT RECEIVED...] APPLICATION REGULATORY APPROVALS NOTIC MAY 12 2023 BUILDING DEPARTMENT By: Address of Proposed Work: S a ores 1 [� Scope of Proposed Work: 1 4.1.{C D 130 c3 1 T rM/1 son ( 'i 1e q, 03uT Gn4 1.-foil'h f k�r m Ih Date: S"-' /a-02d3 Based on the scope of work described above,the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept.-508-398-2231 ext. 1241 Conservation—508-398-2231 ext. 1288 Water Dept.—99 Buck Island Road, 508-771-7921. Old Kings HWY. Hist. Comm. --508-398-22631 ext. 1292 s Engineering Dept.—508-398-2231 ext. 1250 Fire Dept.—Kevin Huck/Matt Bearse,96 Old Main Street, SY Note:Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. Ail applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt cknowledgement: Cr- I 1 ,1 -,3 , App1 nt's Signature Date Rev. March 2022 r.....---------------"*"'"*. 1 • • qF•yaR BUILDING PERMIT APPLICATION '�'®Stlii 4 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE,OCCUPANCY OF, • Syt.•., •• OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING, Ct?„' , Town ofl•trntouth Building Department t 1-16 Route _ • Yarmouth, MA(l2664--l492 Tel: 8 398- 3I elt.. 1261 Fit 08.398-0836 Office Use Only Planning Board information Assessors r.loartrtsort ilderritatkiit Permit to.�.2 3-2- Date, .._; Wit'Tyoll l`tai7 Permit Fee $ E Dale Rttcortp Date - New . Deposit Rec'd. $ Date Ilan N,n. 1.4 Pity Diewesient Net Due $ Other LotArils(soFi,otttope(It) Lot Coveragei ThItt Section far Cifflt Us Or f Building Permit Number: Date Issued: • sltntature I PAY' cart e of E3c iEka hanctt Bulidng Ofiir Dom. is Is not.;. ,,;fellitidrell Sec:tbrt 1 - Site Information 1.1 Proper Addrirssa 1.2 Zorn Information Zoning District Proposed Use 1 1.3 Building Sertbaeoks(ft) • Front Yard Side Yards Rear Yard Required Provided Required Provided Required; P'_rad 1.4 lid ahr Ply(141.G.1..ee.40.$54) 1 Flood Zone Public Private Zone . BEE Section 2- Poverty Authorized Agent • Name ,.mot �� if�`.' KV�,' t12- �1, V4���lk�v\ (prim Mai ing:Adel Ss: Signature • Tel3ftone Telephone Email Address: 2.2 Authorized Agate* Harm(print) ' Moline Address: Signature Telephone Fax Set tiOn 3-C tf1lC for--SeMceS 3.1 Lieamsed Construction Suparvlisor: Not Applicable �] rtes D a a .A_rls t v,.(e ‘ . 1.c,inio.,,i 1.,.‘c‘, c,s,idlotD - —714 --aI '� t�[ c • Tlp t j C '� /ra Date tore Telephone Email Address: IQ via/ .x 5Cn jll‘,1 )1kdo 3.2 Registered Home Improvement Contractor. Company Name Not APPe ❑ Registration Number Address Expiration Date Signature Telephone Section 4-Workers'Compensation Insurance Affidavit(M.G.L c.152 S 25C(6)1 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 I Not Applicable 0 Name(Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s)I Area of Responsibility Name • Registration Number Address Signature Telephone Expiration Date Area oI Responsibility Nanno' • Registration Number Address • Telephone Expiration Date ' Signature • Area of Responsibility Nausea . Registration Number Address Signature Telephone Expiration Date Area of ResponsibilityName Registration Number Address Signature Telephone Expiration Date • Section 5.3 General Contractor Not Applicable ❑ Company Name . Person Responsible for Construction Address Telephone Signature . , Section 6 Description of imposed Work(check all bfe) • New Construction CI (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms •• Existing Bldg. Repair(s) ❑ Alterations ❑ Addition CI 2 Accessory Bldg. ❑ Type Demolition Other BriefDescription of Proposed Work: I n Section 7- Use Grow and Construction Type 1 Buiidbg Use Group(Check as applicafe? Construction Type • A AsssE1+.LY ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ .. A-4 E < A-5 18 ❑ B BUSINESS ( '. 2A [] E EDUCATIONAL ❑ 2B ❑ F FACTORY ❑ F-1 ❑ • F-2 p 2C CI H HIGH HAZARD 0 3A CI I INSTmJ 0/%1AL ❑ • h1 ❑ M2 {, 1.3 C ` -3a [ ; M MEFlCHANTI(.E ❑, J 4 ❑. r R RESIDENrnal. p R-1 ❑ R-2 p R-3_ Q SA ❑ S STORAGE 0 s-1 Q s-a p sa p U UTILITY El SPEgFW. M MIXED USE ❑ SpECIR1R S SPECIAL USE 0 SPECIF1f 1 Corr lete this-section If existing building undergoing.renovas additions afxVor-change in u 1 • Existing Use Gruup: P Use Group: ' Existing Hazard Irviex 780 CMR 34 Proposed Hazard Index 780 tit 34 Section 8 Building Height and Area Building Area Existing Cif applicable) Proposed Hunter of floors or stories include basement levels Floor Area per Roar(sf) Total Area AN Floors(sf) Total Height(ft) Section 9= STRUCTURAL PEER REVIEW (780CMA 110 11) Independent Structural Engineering Structural Peer Review Rehired Yes No SECTION 1 Oa OWNER AUTHORIZATION-TO BE COMPLETED WHEN • OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property, hereby authorize is act on my behalf, in all matters relative to work authorized by this building permit applicatfon. Signature Of Owner fiat® , SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION I. , 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. • Print • Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item ' Estimated Cost(Dollars)to be completed by permit applicant 1.Building 6©d I 2.Electrical 00 3.Plumbing/Gas • 4.Mechanical(HVAC) • • 5.Fire Protection 6.Total:(1+2+3+4+5) • 7.Total Square Ft.*row sins i additions Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old IGngs Highway&Historical • Commission approval (if applicable) . • ti The Commonwealth of Massachusetts , �it Department of Industrial Accidents =l� 1 1 Congress Street, Suite 100 • i Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): T c,/d1 _ r'-. . Address: r frn f<o. City/State/Zip: S r ckf 1^1 Phone#: — — Are you an employer? Check the appropriate box: Type of project(required): LEI am a employer with 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 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 property.mY 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. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12 El Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.; 1. .❑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. *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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. /Sinaire: Date: � /2 —0°D 3 Phone#: 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 4rT1S Rd Work Address Is to be disposed of at the following location: Nit Ma/ f`'� 1/4//re/ f} (ci .d I Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 0) 5 Signature of Applicant Date Permit No. • • • • •••• ••, Commonwealth of Massachusetts • Division of Occupational Licensure Board of Building Re9riiiltions and Standards ConstryttfoRES145rvisor 4,e4 11" CS-107082 Lc, Ogires: 1012012024 JAMES DEA t4 2 IRIS ROADz WEST YARMIJ 4-0/..rNaND- Commissioner t • •