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HomeMy WebLinkAboutBLD-23-003303 5, DocuSign Envelope ID:4A9185DD-203F-4C88- BUILDING B Ac99 8PERMIT21 APPLICATION _ - -g, 4Tii. AppuetkoTtON TO UCEINSTRUCT. REPAIF1,P.ENOVArE , CHANGE , , , ..%.", oq ',r- CP,nL,SPI ANY tilt DING OTtilLFI THAN A ONE OR TWO F MI Y 0 NI-I.LING T Yarmouth Building 1)e1-tairinrut JAN 17 2023 ,, ,mouth, NIA 02664-1'19'2 ------.- Tel; 50g-39g-223i ext. 1261 Fax 508-398- 1 DING DEPA7FT.f ENT 13 y Office Ilse Only i ' lanning Einat4;ngcnnelinn Asussais Dew itrrien1 Inlonnetlet ,! i r, Ptfidit No. eth-ei -00..%Pe ill f . ee $ F, r,:neo,Anent.Ale _ 1 '6\" i I Deposit.Rec'd. 00 tO Le irdi3 _ :Ian i-et:rata:b.:nate__,_____ , 1.4 P.Tnierly Dlinnnialr leo I : \ ). . 14 Net OW $--(fity Li 1 0Thet I 04 Area(V) I Pontage(14 Lai-werao This Section tor Building Permit Number: , " Date issued: 1 ..,,,,,,./ 1.1•11y.••• ••••710.••••• 'Signature: ..___ -_- c --g_e_< j),— 1 7-(Ask [ Certificate of Occupancy Buirerva Vivre; Dale is :Inn* _fr.licrod ‘...--..... ..,_..„... SeCtiOn 1 • Site Information; KECEIVEb 1.1 Property Address: i 1.2 izning intrmattor: DEC 13 2022 13 11:0:1dling SetbacHro(ft) - ---- ZOfting District3.„.— BUILDPARTIVIENT i ' 1 FisquireciRear Yard Front Yard .euired i Pit:Ark/0d ,. Side Yards 1 Recrtirod I Providod 1.4 Viteter 1:upete MULL C.40.$S41 1.5 Flood Znne srdarmatkm: Coirenentm -... r Pubic F-'.Iva.r,„ Zane, Ell-E: — . ......... i Pr Ey')led -- -- - —.......—.. .7. LSeCt_ Ion 2 - Procl.erty Ownership/Authorized Agent I . 2.1 Owner ot Stecurek Zehao Xie 39 Elmwood Street,Unit 3,Somerville,MA, 02144 NAime( in'i Mellinj AAA:4 CM"; .r-i2.40.7nt. 60855601010 xzh0210339@gmail.com _ .1...horte irerrotrsre [mail Address: I f2.2 Authorized Agerill ) - ___Ii)z A,', ,ti,"6:- _S-: Hans?(print) .4.' Aoloilinj Mires s. _ 1 ,!" ' '•,r __t4 J,1 fri-foi---ii 51—7Ncx I Telephone las _ /-11(.1444 ( C. r- _ Ad , - Email dress: li — _ S•••'••,e.,.c., ..t,ro vn? :_C.. o‘.ns itneru-ction tM. 0 3.1 L1k.ns.d Construction Super vi sor: )A, Nosp ica. lts j I Lcere hner)JI : . Avii tuk L ,, ditat ,2_ _14. 6- 109 0 7 71 Addrer , _ fur _...6.44441.13cas_ Telephoto Email AtidreSs: , kg, / //31-',.?0"'I 1-( ..-- - , p -l'Ot) .71e_S aza c Oy , A e--/- • Section 6 - Description of Proposed Work(check all applicable) Nev;Construction ❑ I (tor multiple family only) No.of Bedrooms (for multiple(amity only) No.of Bathrooms Existing Bldg. 2 I Repair(s) Zr,,I Alterations ❑ Addition ❑ I Accessory Bldg. ❑ Type 'Demolition Other Specify: P fY: I Brief Description of Proposed Work: • TC-Nav e �c{Y,ki N aC.Mu.}!; . �Gn V ei ra M+? ) r .�L. 4 '1.`Lt. Cc)115--Fir-cAc4- 'i At• rt:(.R Qom,f-rt•k-�al; P�ct PLct n� i�1 c4�ar0� 'c,:v j' ) �' K1 Cc C.Q ► •I, Le Lui. r7D ay. Q } �'�f `2 p c. .Jil o,i H CS,,,,`�no N('4v !`n <`, >�4� PCA.t'�°t -- 7 E�+/Y i3 Ck.c c� Ire IX -Si '„n. 'c fz�_ . Oct-1-S : 61( Section 7- Use Group and Construction Typ� Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 0 A-3 ❑ to I] A-4 Ci A-5 [�: 18 Q B BUSINESS Zi T' �+� 2A jik E EDUCATIONAL 029 ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C 0 H HIGH HAZARD ❑ 3A I INSTITLMONAL ❑ 1-1 0 1-2 ❑ 1.3 ❑ 3B 0 M MERCHANTILE ❑ ❑ 4 R RESIDENTIAL ❑ R-1 ❑ R-2 D R-3 O SA ❑ S STORAGE CI U UTILITY Cl SPECIFY: 0 5-2 0 SH g/ SPECIFY: T� • M MIXED USE SPECIFY: S SPECIAL USE SPECIFY_ (Complete this section if existing building undergoing renovations;additions and/or change in use.l Existing Use Group: /4 . Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area Building Area Existing(if applicable) ' Proposed ' Number of floors or stories — include basement levels 1 Floor Area per Floor(sf) Total Area All Floors (sf) lb -` Total Height(ft) — Section 9 - STRUCTURAL PEER REVIEW (7E0CMR 110 11) I - Independent Structural Engineering Structural Peer Review Required Yes No... iltr- SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN V OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner of the subject property, hereby authorize • :)tvl C'..i- ,ti.1; ei^i to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date ‘ The Commonwealth of Massachusetts li fit Department oflndustrialAccidents =sully 1 Congress Street, Suite 100 •••i=!° Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Inforgtation Please Print Legibly Name (Business/Organization/Individual): T � co-yi C,l &Lc- ,,: "/ N C Address:c) ,?., , c.) yeNrde- City/State/Zip: 4 s r Pk/. .1 i e /,Phone#: j L+S-I — 7(s' "l Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with employees(full and/or part-time).* 7. ❑New construction 3.0 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. I am a homeowner doingall work 9. ❑Demolition ❑ myself(No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property.ro 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. 12.D Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that check box#l must also 511 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. Tnsurance Company Name: Sr Le(c-i t fJ S L.1 raUntiG2 Policy#or Self-ins.Lic.#: j'C--- Cu I)Z Ll a q '7 Expiration Date: O,3/ie / , - *3 Job Site Address: !() C3 a-S3 S• 412.kle Ll City/State/Zip: St'ul h /0 ocol J II Attach a copy of the workers' compensation polici declaration page(showing the policy number and expiration datk). 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 c under the pains and enalties of perjury that the information provided above is true and correct. 4Signature: Data• /oz / /,.), Phone#: u 01 — L(S/ I 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#: SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION I, `` ' 0 ig9 , as Owner Authorized Agent hereby declare that the statements and information on the forgoing application are rate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. fiAFTv rJ v rn4 eS • Print Name ignature of Owner/Agent Ddte Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completer.by permit applicant 1.Building p y. 2.Electrical 3.Plumbing/Gas 4.Mechanical(tiVAC) 11111111111.11111111111111 5.Fire Protection 6.Total=(1+2+3+a+S) i 7.Total Square FL(Ix stitmuies&additions) Check Below D Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223!1 ext.-1261 Fax 508-398-0836 Office of the Building Commissioner BUILDINNG 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 to 5 t2 '(Z I 01`o 74 2 p-1 OU ki Work Address Is to be disposed of oat the following location: r p t' �. ; .� R Q. j i¢ N1DA' Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. ///0 .1,e--Yic,, 444 c 30 Signature of Application Date Permit No. 3.2 Registered Home Improvement Contractor. • Company Hams Not Applicable • _ Address Registration Number E:pitation Cate 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 V 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 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 General Contractor Not Applicable D Company Name P Person Res onnsible for C nstruction Address t) 31 �Dc,,.a A-V P F. P. kv r —45 —7V c i Signature �� Telephone ® DATE(MM/DD/YYYY) AC ` O CERTIFICATE OF LIABILITY INSURANCE 08i25/2022 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: Autumn Lee Howe Lezaola Thompson Insurance tAlC.No.EMI: (401)434-7203 HONE FAX No): 2761 Pawtucket Ave E-MAILRSS: Autumn@Lezaola•Ins.com East Providence, RI 02914 INSURERS)AFFORDING COVERAGE NAICO _ INSURERA: Selective Insurance 12572 INSURED INSURER B: Selective Insurance 19259 T&J Construction,Inc INSURER C: 223 Don Ave INSURER D: East Providence, RI 02914 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 95965385-0 REVISION NUMBER: 31 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 COND'TION 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. INSRT TYPE OF INSURANCE INSD WVD I POLICY NUMBER 1 POLICY EFF POLICY EXP(M LIMITS MIpD/YYYYI IMM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY IS 2441887 03/19/2022 03/19/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO 1 CLAIMS-MADE ^J OCCUR PREMISES(EaENTED occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO- X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ A AUTOMOBILE LIABILITY S Y441887 03/19/2022 03/19/2023 (E°acccI dentSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X j AUTOS HIRED ONLY X AUT NON-OOS ONWNELY D PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAR ,OCCUR EACH OCCURRENCE $ EXCESS LIAB 1 CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ ri B AND KERSO MP NIA TI rN WC 9084297 03/19/2022 03/19/2023 X I STATUTE 1 ER TH- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000 i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth MA THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE I :a:IXt...1-7 -f!+4- 6 -V.' ' 1' (ACH) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by ACH on 08/25/2022 at 08:50AM Commonwealth of Massachusetts ® Division of Occupational Licensure Board of Building Requlations and Standards Const( Tl tS rVisor Tres: 12113/2024 CS-109077 ANTONIO J FONTES 223 DON AVENUE EAST PROVIDENCE RI 02916 tY 14)1J.v ` Commissioner to, ' oNi by TOWN OF YARMOUTH °: HEALTH DEPARTMENT "6.. ,1kPERMIT APPLICATION SIGN OFF TRANSMITT To he completed by Applicant. DEC 27 2022 Building Site Location: /n e sm c -_ �:' nki' BUILDING DEPARTMENT By Proposed Improvement: ( ( 'on (a =; i' L.r- 1,11 AA./ L r("A<ls �,v /- • .1 c A ' ,9 r2,'c_ ! ,..(� ritr'aIj r t- �n1iz, £ / CLc•7, ,,,,e AJ2L IN,L1' L. ' v,,.• n,t•'S ,.a<'cM 44 , v,i„iL‘GI, i 12e J ( ',if) 4 l l,:;,y -7 ,'i F o pie t� �a.LI ALP` 7 ) L Q a 4:,i / b F 0 i.� , S.+- Applicant: /,,_ !.; Cat,.) v \ ()_ryl 4 t C.. Tel. No.: ; r )— 7 k ,./ Address: L 2 ' , , , / , F'/w , kt,i ' G Date Filed: / **If you would like e-mail notification of sign off please provide e-mail address: Owner Name: Owner Address: Owner Tel. No.: RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, `..,., and septic system location; DEC 13 2022 . (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — HEAL yH E:.::. .- Note: Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer with fee. r r REVIEWED BY: (//, ` DATE: / )' a,7" d-'Z PLEASE NOTE COMMENTS/CONDITIONS: / `T.(-e-A, C c t 1 (3 ,/,-- S w `l ( ,- ,e ,i) l.,, r c F t .-t,c ct . _ t t '