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HomeMy WebLinkAboutBLD-22-006583 c f __..r�..... • . Ar, BUILDING PERMIT. APPLICATION C IE I'�' ... � -v. APPLICATION TO CONSTRUE,REPAIR;RENOVATE,CHANGE THE USE,OCCUPANCY OF, ,:., %% OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWEWNG. mAy ' , . Town or1'art aouth BuildingDepartment ent ` ' ' 1146 Route. 28.• Yarmouth. MA 1/266�[492 8- ILDING D PARTMENT. TCi: 5� 9$- I ext. 126E Fax ', Q8-3q$-0836 sr- « Use Only 3 Board Information Assessors Department Information ' Permit NG. t4^"a': Date Plan Type Map Lai ,....._._.___] Permit Fee l/,�� [-ndorsena D ,_ / Deposita 690.0 Recording Date New Rec d. $ Date PtahNo. 1.4 Property Dimensions: Net Due : o� Lot kU(sfj. Frontage(It)` Build n K sects,f Offlce Use Only 9 rmit.Number. I Date Issuet mill-7'--vragie' Signatures Certifi of cy Building.OThcial Dateer, is Is not._..__ Section 1 -Site infarmat1o,I . 1.A :Property Addrassa 79 WHITE ROCK ROAD s 1.3 zoo,i,rom tioto YARMOUTH PORT MA,02675 Zoning District Proposed Use 1.3 BullidIng Sotibaetcs(!t) Front Yard Required ,Side Yards Rear Yard Provided Required Provided Requited Pcci�mri ;. . .... 1.+1 Water`soppy[-ai_e.so.$Sri) 1.5 Flood.Zon e Coeemi Public Privatia 'Zot :,,--,_-„ BFE _ Section 2 Property. ie AuttiorIZed Ag n, ettt 2.1;Owner o+i R TE KIRKLAND REAL ESTATE LI.0 • 79 WHITE ROCK ROAD YARMOUTH PORT,MA 03076 N \,,,,,i•f 508-362-3798 Address: ........ky ymail . , Si 508-362-3798 �/ /,,. Telephone .. Telephone / `�r"1 Cho tzed Agent ' . Email Address:. _/ Mailing Address: Signature Telephone Fax Section 3-Constkui Sege Email�tddri 1. 3.1 nsid Co teti:con. upsnrlsoR . Net Applicable - �4et M . License Number G , ref '. s w w 3 2 Registered Node in ? mert r , �pae�y Hae z � - ''' Ot Agipi Q • dress Rtran'Number , • $ew -Wo era' on i �t M GL-c.152 M'H( ) ` Workers •art; Co mpete Insu ra}nc e affd avt mu st be ompleed and su tedp m application. Faiilrra .;` to providethis iait iilr Itinthedenraiif ei s ce ofthbuiidmg erit Sgd AdavtA ch V ' . tRV a ei4 Y.1!Y{w .n, ye n 5,Professir nat Design Cor tr�On services for Bulk ;And",-xtires�bf to Corr tr c Control Pursuant to 780 CM 118 "� c in b ore soon 5 e•� ' rtect:: e( - , r .,•n 5 i i t= rittslonal E.ngr'_ ram. aE raes�c�rditf�rty, hares Ftt rim. r. t. , A o,r� W4 e� k.. Srr �ature " 7 crass a s b " C .: 7 y w Y,e ke te xL.- ., .4 0.� k 7. "^" �r ,kilig aw x �1'nx aw s k. :-i <, *,,.w, L'n ^� *,: ° b a r '' a .,. ,4"",:. a Y g . �QC�6-O Attb o Propo V1/Qf1C tOttekk,a, able) New tOnSEructipn ( ror to 1� e xcstttip strut,, u,W family on ii No l i edroo, s...` ._ 1 UD(mu a*mpy£flhl NO of Bathrooms AQ9ssory B Jg 'fgpe D+si` i'it�on �, � ~��; ��i specify; BriefDesc. rlj o0.,:if Prep $ed Work ',;; '' ' • . : s e e -•-:. a R E`BUNK.SPACE'FOR DAY.„CAMP PROGRAM. INCLUDES TWQ HA iGING OOMS Wi7W LOCKERS AND BATHF ** y 7 Use r and oitstnlcb rt Tire ,Use Croup C+�hdc asi or> ont" ` - �t J1s;5EMety A l •d • A-2 Q iA Q HUSii Q 0 I, iN o�r 'a Pi u ura,rrrC Qr 7 d, R� a • C`s s GEp sI � d U usie > t.user Estsfhl9 tJsei©ti>r�p,w f , �Ot .1Fk t1S . . �xTsfing;Hazard s d G00* tJae•C3rot; Pam. rd 78o"GLAIR 34____=,r 5 gnaBuil Ufa �9ht and Ata 3'440rig p,i (ft*ra ors C '' Pam' incwd� o, : Aare Toil.Arrll : 'treat 11o11.) �' 1� r prat:PearR;�vie r F1 _ =£ F M .flaw , SECTION"ii, OWNER' S A4 QMTtA�YOi ,.,.. ,' ... �!!d Merely- u"tho .t4 .. ' .. ' e sWblect�p r R� I. r my bhel#,` _ lxocs alive to-act'on ,., '. SECTION 1 0b OWNER 41�'t'HORM`Z�Q�c�E�'I"D�;�kA "1`to1j • Authorizer'Agent r ;hereby declaretbaf the statements and information on the forgoing application are true and acurate,to the best of mY tnowledg°e and beliefs Signed under the paths and.,penalties of perjury. Sig . . ` - 4,006n,II rvSrRvO- r � 7-:*111 '1142 Cons. n-Commission Rang #*4 rej LA" O tartg Hurrays! Histc rica1 Qo,mmiss �app �flOable) §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 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. (..Ch. 111 150A. �1 �.— 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. IMPORTANT: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 FAX (A/C,No,Ext): 570-226-4571;800-245-2666 (A/C,No): 570-226-1105 209 Main Avenue E-MAIL Hawley,PA 18428 ADDRESS: amskier@amskier.com INSURER(S)AFFORDING COVERAGE 1 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 (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES TO RcENTence $ 1,000,000 B CLAIMS MADE X OCCUR ❑ ❑ PHY220201MSP 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 POLICY —PRO- LOC $ 1,000,000 JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INURY(Per person) $ ALL OWNED AUTOS AUTOS ❑ULED $ ❑ BODILY INURY(Per accident) HIRED AUTOS NON-OWNED IAUTOS PROPERTY DAMAGE $ _ Deductible: $ UMBRELLA LIEXCESS L ABAB �IOCCUR EACH OCCURRENCE $ CLAIMS-MADE ❑ ❑ AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION WC STATU- RTH- AND EMPLOYERS'LIABILITY YM ITORY LIMITS A ANY PROPRIETOR/PARTNER/EXECUTIVEN/A 2022010291401Y 2/1/2022 2/1/2023 E.L.EACH ACCIDENT $ 500,000 OFFICE/MEMBER EXCLUDED? N ❑ (Mandatory in NH) E.L.DISEASE-EACH EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 ❑ ❑ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHILCES(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 4.44.44/64.A nu:0c.... 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 19te. 5 — I�ae .1.14 •VIIIVele 1 4 li�llr 1111111111 -a__________001111111111111111 nor.. IDet tocLe PAY awl cm* „ot , zi 62 N rt a a sz i 11 12' 3`, i rt- • 2' Liu It 1111 ■W � ./ • ,• —•:, '''•''':':''.**!!11''.?"14'-"W/t-',:.... 1.,'."Aii,41,,,T.Alk::'':''s:4"`...•:'.''.:•••'--,4,,C '''• -• iN '. jh4' • 4.-, - 7,..E , :.,, .� _ A • , ::.. KKK , off'°s ;3, -•4 xKKKK... :. . ,, ;*, ;s 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 *X 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 for a 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 C ? Deputy Building inl Commissioner Town of Yarmouth S08-3 5-.22 1 Ext. :1. .`. 9 mailto:tsearsPyarmouth.ma.us 1 tt E. �a ,E 1 .,_- BUILDING PERMIT APPLICATION `�J 3 � P�,n � q- .� APPLICATION TO CONSTRUCT REPAIR,RENOVATE, CHANGE THE USE,OCCUPANCY OF, MAY I m,f`. , d y OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DW {r� ' Tcnvtt cif'Yarn)outh Building Dc'partnlent EWNG. ..BU t_C2it\►Gt�eP ':;�,�,.�,>« 1146 Rc>tite 28 • Yarmouth, MA C) fa6--4492 � -. -- Tel: 508.398-2231 ext. 1261 Fax 508-398.0836 tilv Office Use Only - Rennin Bcerd Infommation Assessor (' Permit N )-22- ate Pin T Department Intorn�tion --- Ty ,Lot Permit Fee $ Endorsement Data Deposit Reed $ Date Recording Date New Net Due $ Plan N 4 Property Di a 1. ttiensletts Frontage tn) Blind! • -errnit Numbell This Section for Office Use On Date Issued: • Signature; Certificate of Occupancy Building official oat le Section 1 - Site Information --__ i,not ,d 1.1 Property Address: HI1 E ROCK ROAD 1.2 Zoning Information: YARMOUTH PO T MA, rS 1.3 BWldlr09 s. Zoning District Proposed Use tbacics(ft) Front Yard R..uired Side Yards Rear Yard Provided R . fired Provided --. Provided IIIIIIIIIIIIIIIIIIIIIIIIIIII ?.4 Wat•,Supply(M.aj.e.40.$so) '1.5 Rood Zone Informatiort Public Private Zone; BFE • Se ction ction 2- Prope Owe - • AUthorizej . , 2.1 owner of Records TE KIRKLAND REAL ESTATE LLC • 79 WHITE ROCK ROAD YARMOUTH PORT,MA 0 675 �., 508 62-3798 Mailing Address �� Si• a 0. 508-362-3798 Telephone �y �� 2.2 Authorized Agent Telephone Email Address; Natime(Print) Mailing Address: Signature Telephone Fax Section 3-ConstructionEmail Address: Services 3.1 U Co on Su Porvison t • Not APplit ahle f, Ad t L. +-"i - 0i S f� License Number‘ AA /� re Tole 7(4 Eve-akin o e Ettaii Atldress• 0 ' 'df+ -t . A . 3.2 Registered Hotm"e I rovemnent Cone- Company Nara* _ Mat Applicable 0 • ,. dress* Registration Number Signature Telephone lr. isaZ Date Section 4-Workers'Compensation Insurance Affidavit(Mat_c.152 S 25C(0) Workers Compensation Insurance affidavit must be completed and submiited with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes ..a....... No ........... • Section 5-Professional Design and Construction Services-for Buildings and Structures Subject to Construction,Conttal Pursuant to 780 CMR 116(containing more than 35;000 c f.of enclosed she) Section 5.1,Elegered Architect: Not e.: Sams ch Registration Number Address eieLiratioritiest Signature Telephone Section 5.2 Registered Professional En'gi1neer(s), Name Aim aee y Address Registration Nienber Signature Tistecihcine Expiration'Date' Area at Rerrioeadbmly Address R Nutnoar Signature ,T fiaphons .eciottiondate Names e;Ry • Address Registration Number Signature Tell. Agoir*I9rt„,pals Noe Mitt*Rey res5 Registration Number Si a gn tu , T iiephonne Oliiration Date Section 5.3 General_Coritract+or • Not Ap prcabte'(14 oar rony; fin} Person !`�� :Res �� '� �� /_ �for � to 4 m� s Mtn Adds f,r , A±� 7.4 3 • j = , Section r escrdpbon of Proposed Work(checectc y, New Construction 0 1 (formultiple family only) No.of Bedrooms (far multiple family only) No:of Bathrooms Existing Bldg. RI I Repairs) 0 i Alterations tia I Addition I- Acri essory Bidg. C) Type Demolition jn Other Specify: Brief Description of Proposed Work: »----- RENOVATION LODGE 3 TO ADD PRIVATE BATHROOM FOR STAFF Section 7- Use Group and Construction Type I Building Use Group(Check as applicapable) Conduction Type • A assErNEILY D a 1 0 A-2 p A-3 0 to (3 BUSINESS Q. A-4 .0 A-S 0 1s E. EDUCATIONAL CI F FACTORY2B 0 0 F-I 0 . F-2 ■ H HIGH HAZARO�; 0 0 1 INSTIiUTIGNAt ' ( �.� 9ACI ;IRF aiGEKtTfAL a f�.� 4 (3 .• • s STORAGE .C] s., CI ��ram ® �a CI ��' SA � u UTILITY CI0 s-a 0 as CI _ ._ M LIME USE SPEtr1E Y 0 VFW S SPECIAL Use - ,0.. SP'SCtFYr. ` Corriplete this.. If exrsttn buildin .�• 9 undergoing.renovations;additions a+ndlor change li uee- Existing Use Group: wed Use Group Existing Hazard Index?Op CMR 34 Proposed � - e Hazard: 780 cry 34 Sadiron 8 Building Height and Anaa • �'��" :. Building Area Existing Cif applicable) • Number of floors or stories „ include basement levels Floor Areeper Floor(st) • Total Area All Flocri Total Height(It) $ tion 9•x-S`f -OI'll,PEER REVIEW(7840.100110 11) Independent`Struc fora)•End earing Saudural,Peer Revre N Raggired Yes „... SECTION 1 as OWNER AUTHORIZATION''-TO BE COMPLETED WHtN OWNE-'S AGENT OR CONTRACTOR APPLIES°'FOR BUILDING PERMIT i • I, 0,1. ®e st...A I ,as OW er of the subject property, Pnl►• hereby.aut ,. r1�1'\ my beh- - -tte- relative to work authorized by this buildingto act on _ 3� �Ir?�it application. Signature o owner fI2j Z • SECTION 10bOWNERIAUTHORIZED'AGENTDEt I A` `iO.N`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. Signe• - ,er the pains and pe I afties of • perjury. + A a i !JAI" 64 9/)61 ti • Print Signature of• a. to-c2.-' Date Section 11 - E.. , •TED CONSTRUCTION COSTS !tern 'mated Cost(Dotiars).to-be ' completed mpieted by point applicant 1.Building 2 aural • a Plumbing i Gas 4.mechanical(FHVACi Li/ 5.Firs Prntection 6.Thtahr(1+2+3+4+$) ^� 1 ' 7.Thai Square Ft Newt si a&s iMbn -# t)r tt)0 - ' Check Below C Conservation-Commission Filing (if applicable) CI Old Kings Highway&Historical Commission approval (if applicable) i , , • r The Commonwealth of Massachusetts , Department of Industrial Accidents � 1 Congress Street,Suite 100 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): 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.01 am a employer with employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Re Rem delinruction any capacity.[No workers'comp.insurance required.] • ❑ oeling • 3,[idI 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 my property. 1 will t0 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.0 Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 12.0 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•0 Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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: AM SKIER Policy#or Self-ins.Lic.#: 2022010291401Y Expiration Date: 02/1/2023 Job Site Address: 79 WHITE ROCK ROAD 02675 Attach a copy of the workers' compensation policy declaration page(showingtthe policy numberand epM ation 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 ly uluf��n and penalties of perjury that the information provided above is true and correct Signature: / MAY 5,2022 Phone#: 508c381-3798 Date: 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): I.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 508-398-223*I 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_L Ch. 111 150A. } MAY 5,2022 Sign "e of Application Date Permit No. ..... ::., ' a ' . -' •'••:::',I.:4:14.:::".:14.*4''''''. ..45...:.....it:.:4 ''.:''.''...:.1•:"::..1..•....:::'.'.::......,...:....::.%:.:.i.•l:.••..•%'....•.....,:'..1:.i.:.',.....:....."!.'....;,..:......:.....1.....'..:.,.•,.,..:,.:,,.",:,,... i..:•"...,...••'•'.•.::.:.::.::•••. %' :. 3 .{..c:.a" . 'e. 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