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HomeMy WebLinkAboutBLDC-23-11 (5 /of1z5 r• .-oF•Y�,4 BUILDING PERMIT APPLICATION . { ---'Ire.,* APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, o e,, _\0 I OR DEMOLISH ANY BUILD NG OTHER THAN A ONE OR TWO FAMILY DWELLING. �� y Town oiYarmouth Building Department % 47T4C n CCS �- �`••'. 1146 Route _i • Yarmouth, MA 09664- 492 Tel: 508-398-2231 eat. 1261 Fax 508-398-0836 .� Office Use Drily Planning Board Information Assessors Department Information: Permit44.)'�� - 13—/ ate Plan Type_ Map t Permit Fee $ 3200 , Endorsement )ate ('�Z. Recording Date New Deposit Rec'd. $ ,�jate n Plan No. 1•4 P Dimensions: 3 b Net Due $ ) �y � �,��� Other Lot Area's�� Frontage tt / • 7�� aU ? D O Lot Coverage This Section for Office Use Only Building Permit Number Date Issued: 2 Signature: _ �'r..2 ,. . Certificate of Occupancy / / ' Building Ot Date is Is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: i1--. Zoning District Propeded Us* 1.3 Building Setbacks (ft) J ' Front Yard 01MEi�d 4- Side Yards Rear Yard Required Pr Required t I Provided Required Provided *(30 ./= . r V .. ttr 49-of /0 , 3o/ AvA, 1.4 Water Supply(M.O.L c.40.S 54) 1.5 Flood Zone information: Comments Public Private Zone: _ BFE: Section 2 - Property Ownership/Authorized Agent 2 Owner of Record: e-r4 ,7.( /�A-1rr1 E C �d' el�t 1�/ - r/� • Nam nt --orT , ,._ I L_- 7/� . Mailing Address; Sig ture Telephone el p Email Address: 1 2.2 Authorized Agent: ?t rthuu ` ,, �r e - ) VYj o�.,g- kikke- T; fel/1,1-n rt i ' — 6-MikerSoeirilOY1V440118 N e (pr t' ` Mailing Address: &IMA4 �17f,L/ 3h�-Y ' ignature Telephone Fax Email Address: 11 Section 3 - Construction Services '\J4YMO (�V 1i-f rq 4)AL • LQ 3.1 Licensed C nstructlon Supervisor. Not Applicable D ' �-\111- Kin N/ e - /o-7/g S I or'r ,, ,,, A1 k o?oI Lic s Number 7 Q Address Y / ��—�v ( / (� 31 ; � Y. n mex:.,, • C' dYh. Y" Expi lion to Signature Telephone Etoail Address: 3.2 Registered Home Improvement Contractor. , . Company Name Not Applicable 0 -- Registration Number Address 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 ATdavit 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 0 Name (Registrant): Registration Number Address Expiration Date . Signature ' Telephone Section 5.2 Registered Professiort,'Engineer(s) Name Area of Responsibility Address . 1 i f. Registration Number Signature Telephone ' Expiration Date r • 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:S General Contractor ' , • • ; . A ...elf/a j/ 56biftp)-ic Not Applicable. ❑ ame ` 1` Comps N �. it L4✓r am . • • . • Person ,9spori il'!.le for C nstru i rt • r Address )(/6 7.c 'Signature Telephone . ! Section 6 - Description of Proposed Work (check all applicable) • '. New Construction El (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ❑ Repair(s) tit r Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: i Brief Description of Proposed Work: Q-ei0 1.4-W—. 1) )- ' 76/60‘1 -COY Si*/Arei lius Pl.tu-1,05 ei)-\, • Section 7- Use Group and Construction Type Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ to ❑ 6,, A-4 ❑ A-5 ❑ 1 B ❑ B BUSINESS d 2A ❑ E EDUCATIONAL ❑ 2B ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-1 ❑ I-2 ❑ 1-3 0 3B ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL a ' R-1 ❑ R-2 ❑ R-3 I❑ 5A ❑ S STORAGE ❑ s-1 ❑ S-2 ❑ 5B i] 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: /3 s•I Existing Hazard Index 780 CMR 34 Proposed Hazard Index 730 CMR 34 Section 8 Building Height and Area • Building Area Existing (if applicable) Proposed Number of floors or stories include basement levels ✓ ''A..f4r' Floor Area per Floor(sf) I Z'n G 1Ha Total Area All Floors (sf) 1.11 (i d t7A-tYe Total Height (ft) 2 I .! j/�. . Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No J SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNE 'S AGENT 0 CONTRACTOR APPLIES FOR BUILDING PERMIT I, -e ' - Grli`G v‘. , as Owner of the subject property, hereby authorize L_ / 4 L4jJU1J to act on my a alf, in all afterrs/relative to work authorized by this building permit application. Signature of Owner Date • SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION ' , I, /4"(APCV'r 0/(j /G' �' ' ►/r / 1 l , as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my kno wiled,ge and belief. Sign und e ai land penalties of perjury. Print N e - 2-y Signature f- wfier gert Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building ,f CCU O a Electrical I, 3.Plumbing/Gas c�(� . j 4.Mechanical(HVAC) 5.Fire Protection E.Total=(1 +2+3+4+5) 7.Total Square FL(Icy new smcnnes&addi6,n) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical • Commission approval (if applicable) • The Commonwealth of Massachusetts L Department of Industrial Accidents 1 Congress Street, Suite 100 i Boston, MA 02114-2017 mo SY• www,mass.go v/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Legibly Name (Business/Organization/Individual): 2tA/") 444X/" Address: 15 4v' ,4j City/State/Zip: n41J Phone #: 5e2I3O o� Are yo an employer? Check the appropriate box: Type of project (required): 1. I am a employer with L employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Rem Newm construction any capacity. [No workers'comp. insurance required.] • odeling 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 [1] Demolition 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. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 13.0 Roof re airs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other t�l �erhe `. 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. r � 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: ,SC I1 fr12 &17€C -e-6-'&1-4~-3 Policy#or Self-ins. Lic. #: 1P--ft..) eon 057 •2,2,- iv z3 Expiration Date: /q/ / Job Site Address: 5 q---57 3 et'Attach a copy of the workers' compensation. City/State/Zip: oli , �` j�4 ox, y p cy declaration page(showing the policy numr 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 der the ai sand penalties of perjury that the information provided above is true and correct. Signature: J��Date: /549 3 Phone#: 5-0 gj ec,O 1751/ 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#: • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enter rise,and including the le al Lepresentatives of a deceased employer, or the receiver or trustee of an individual,partneishzp, sgoc?ati©n or othe legal entity,employing employees, However the owner ofa dwelling house having not more than three apartmen s and who r.e i4es therein;or th'e occupant of the dwelling house of another who employs persons to do maintenant:e, construction or?epali work on such dwelling house or on the ground.or building appurtenant thereto shall not because of such eirrprgymentsbe,deemned to be an employer." .1 • , r t.; MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the.applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. • The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia 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 5(; L( ai 2 9pjy' Work Address 5 5 Is to be disposed of at the following location: Ca Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. r \ (-5- \/ - 2-3 Signature of Applicant Date Permit No. z i � r '`# !Ra CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/23/23 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 have ADDITIONAL INSURED provisions or 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: JIMMY HINDMAN Schlegel&Schlegel Ins Broker (a/c°N o.Exc): 508-771-8381 FAX 34 Main Street E-MAIL (A/c,No): 508-771-0663 West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURANCE 14788 INSURED INSURER B: TRAVELERS A GRADE EXTERIOR SOLUTIONS LLC INSURER C: 393 BUCKSKIN PATH INSURER D CENTERVILLE,MA 02632 INSURER E: 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 CONDITICN 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 100,000 A OWNED SCHEDULED M1T7484M 02/10/23 02/10/24 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS300,000 HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? Y N/A 7PJUB6R08057122 09/23/22 09/23/23 (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CORPORATE OFFICERS HAVE ELECTED NOT TO BE COVERED UNDER THEIR CURRENT WORKERS COMP POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT ^ WEST YARMOUTH MA 02673 AUTHORIZED REPRESENTATIVE ! ` l ©1988-20, 5 ACORD CORPORATION. All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACO IFDivision of Occupational Licensure Board or Building Regulations and Standards Constr rAkervisor tP CS-107181 15;}.3ires: 05/27/2025 ILYA LAVREfOV ' . t 13 BIRCH STREET fil) , HYANNIS MA) • • . • "tF •othrinit' 4b/tva!".1.3` Commissioner I • • • 4-3 c.) COMMERCIAL ONLY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: kao cf 7 947103744 Scope of Proposed Work: e)1 T3 v-Ok en v vt i;, Z A/4i 1,u le-, /C )01c e-ss .€c, r-e-65 iI 34, Date: 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 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. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement: `,_ /43 3 Applicant's Signature Date Rev. March 2022