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HomeMy WebLinkAboutBLD-23-005805 WITHDRAWN . L.: >' ,,olfAwr ;of•Yki. BUILDING PERMIT APPLICATION -(=Ittc APPIJCATION TO CONSTRUCT,REPAIR,RENOVATE.CHANGE THE USE,OCCUPANCY OF, -, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. 0 •�..k Town of Yarmouth Building Department .c" ep 1146 Route 2S • Yarmouth, MA 02664-1492 1-el' 508-398.2231 ext. 1261 Fax 508-398-0836 Office Use Only Planning Board Information I Assessors Department information: Permit No. 6UU 3-016 e Plan Type Mao Lot Permit Fee s Endorsement Date / Recording Date New Deposit Reed. $to i D ate Li Plan No. 1.4 Property DimensifmreT Lot Area(et)Net Due ( DamAreaFro ([_ E GFE D This Section for Office Use Only Building Permit Number: Data issued: APR 18 70073 •Signature: Certificate of •-- e„_ ___--,--___- &Acting Official Data is Is not BUILDING Q E}'A RT M f N T Section 1 - Site Information 1 1.1 Property Address 12 Zoning Information: Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided _ Required Provided Required Provided 1.4 Vaster Supply[M.f1.L c.4a.S 54) 1.5 Flood Zone kdamatiort Comments (Pubge. Private Zone: 3FE I_Section 2- Property Ownership/Authorized Agent l 2.1 Owner of Recce ` S & C Realty Investment Co., LLC 169 Main Street Stoneham, MA 02180 / Name • t) • Mfg i 781-279-0290 sc@coutomanagement.com s' "� T e e • Telephone Email Address: t\ 2.2 Authorized Agent I Mailing Address: /%_ Lam- - 9. 7 40/ 4 /— -p -( f4'Y �t 0 , <-; gnafure Telephone Fax r�': I ` Entail Address: _Section 3-Construction Services 3.1 Licensed Construction Supervisor. Not Applicable License Number Add y A .P. f.15// (''c'L',- ,�,,�. k c;� (4IC- C 5 lt� 7 7 -41„)L( - 4C —jt ' is r !'�`�;J"�t 1 4/�7f�t/ r�xn�- t�1�c_i,.'xf��tianDaie - Lure Telephone Email Address: f�j f /'�/ . ,-) 0 _ a 4i) 44,J-) 2 .. co , ne 1 • 3.2 Registered Home Improvement Contractor.) • ,_ Company Name Not Applicable ❑ - Registration Number Address Expiration Date Signature Telephone Section 4-Workers' Compensation Insurance Affidavit(M.G.L c. 152 S 25C (6) I 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): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional EngineerR Area of Responsibility Address Registration Number Signature Telephone Expiration Date Area of Responsibility Name Registration Number Address Signature Telephone Expiration Date Area of Responsibility Nam Registration Number Address Signature Telephone Expiration Date Area of Responsibility Name Registration Number Address Signature Telephone Expiration Date Section 5.3 General Contractor 1 r(^ Not Applicable ❑ Company Hams rn S C p(-Y\ e C. P4rson Responsible for Construction . -)-� ;+)c.- r .4-1/d , PACT PiCDU . rP 0Dr,_iL Address -- c - 4 I)I-4 5-1 --7 -/ \. Signs r Telephone • • .-oF'-'1'.41;4 BUILDING PERMIT APPLICATION .,*CE . APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, F•„ _ i C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. Town ofYrrrnouth Building Department M47TiCACCS -'••- *s 1 146 Route 28 • Yarmouth, MA 0266.44492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 Permit No. Permit Fee Office Use Only Planning Board Information Assessors Department Information: Date Plan Type Map Lot Offs Endorsement Date Recording Date New Deposit Rec'd. $ Net Due Date 1.4 Property Dimensions: Plan No. Other$ Lot Area(sf) Frontage(it) Lot Coverage Building Permit NumberThis Section for Office Use Only Date Issued: Signature: . Certificate of Occupancy Building Official Date is Is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: wF S Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required 1 Provided Required q 1 Provided 1.4 Water Supply(M.Q.L e.40.S 54) 1.5 Flood Zone Information: Comments Public Private Zone: BEE: Section 2 - Property Ownership/Authorized Agent 1 / 21 Owner of Record: �/ Name(print) ,. / TelephoneMailing Address: ✓ Signature // (` Telephone 2.2 Authorized Agent:I Emai! Address: Nam7(print �t—P`'J` SA ' C e? 4l 'r� `� Mailing Address: 7 ignature Telephone Fax Email Address: i Section 3 - Construction Services 3.1 Licensed Construction Supervisor. Not Applicable `f 7,11` '/\4 0t -l-i-r C c /- /�c ��I'_` 1� License Number Add ss • .Qr=tc` Q(.LE cps G/f �r ^�, Af Cry --f3U117 ,Signs ure 0� I ' 01_ + �f- ��s ) /L�'Z'ti1•iPs,,ler- X. Expiration Date Telephone Email Address ,u•T 1 Section 6- Description of Proposed Work(check an applicable) New Construction ❑ (tor multiple family only) No.of Bedrooms (tor multiple tamiN only) No.of Bathrooms Existing Bldg.. Repair(s) ❑ Alterations ❑ Addition 0 Accessory Bldg. ❑ Type Demolition Other Specify: r Brief Description of Proposed Work: COAy s r . .1--- a\I NU(A ) t fv4{ 2 P A e-4 i.V /0 (Al4 l-.L- J�-w FL©p Lc_-). L � /�1EW D P Gi.,l.,A,. �'.t /.i E-tn) ._ r� - t.,J 00c) •Or P 5,.:-�- d Section 7- Use Group and Construction Type Building Use Group(Check as appitcapable) Construction Type A ASSEMBLY 0 4-1 zi, A-2 ❑ 4-3 ❑ 1A ❑ A-4 0 A-5 ❑ 1s (3 B BUSINESS vi 2A a- E EDUCATIONAL ❑ 2B ❑ F FACTORY "-❑ F-1 Q F-2 Q 2C Q _H HIGH HAZARD I] 3A I]I wsTmmoNAL ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3e Q I u misecHANTTLE 0 1 Q R RESIDENTIAL ❑ R-1 ❑ R-2 O R-3 ❑ SA Q S STORAGE ❑ S-1 ❑ S-2 O se Q U UTILITY El - r n SPECIFY: _ U LazED USE ❑ SPECIFY: _ S SPECIAL USE 0 sPECtFY Complete this section if existing building undergoing.renovations~additions and/or change In use. Existing Use Group: I Proposed Use Group: Existing Hazard Index 780 CMR 34 I Proposed Hazard Index 7'30 all;34 Section 8 Building Height and Area Building Area Existing(it applicable) Proposed Number of Doors or stones include basement levers Floor Area per Ftoor(sf) Total Area All Floors (sf) Total Height(It) Section 9 -STRUCTURAL PEER REVIEW(788CMR 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 ! Salvi Couto ,as Owner of the subject property, f/ I' hereby authorize r 1 7- c or, c (?k C'4. 0 ij to act on my behal in all mars relative to work authorized by this building permit application. 2/17/2023 i Signature of Owner _- Date SECTION 10b 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 Name Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building goo- 2 o 2.Electrical /NIl 3.Plumbing/Gas pi 4.Mechanical(HVAC) 5.Fire Protection 6.Total=(1 +2+3+4+5) 7.Total Square FL pa new strictures&addib ) Check Below D Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical • Commission approval (if applicable) • • Section 6 - Description of Proposed Work (check all applicable) New Construction ❑ (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: Brief Description of Proposed Work: Cntv)54 P4 :.i i n14 _al_ ft Pa-1 +-:OAi yv-c(Q�> 6/_.Q.�) 00, "i r`t P. �1 , ='7�e ' Cam:-t , 6 Br _Davr Section 7- Use Group and Construction Type Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-t A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ iB ❑ B BUSINESS ❑ E EDUCATIONAL ❑ ❑ F FACTORY ❑ F-1 ❑ F-2 C] 2C ❑ H HIGH HAZARD ❑ 3A ❑ _I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A S STORAGE ❑ s-1 ❑ S-2 ❑ SB ❑ U UTILITY ❑ SPECIFY: • M MIXED USE ❑ _ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this section if existing building undergoing renovations, additions and/or change iri 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 (if 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 1 I, , as Owner of the subject property, hereby authorize Ti". �J, C po,t 57L 4— i � to act on my behalf, in all matter relative to work authorized by this building permit application. Signature of Owner / Date ACORO) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.--- 04/14/2023 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 CONTACTNAME: Autumn Lee Howe Thompson Insurance Group (aCN No.Exth (401)434-7203 FAX INC.No):(401)434-8698 940 Waterman Ave E-MAIL ADDRESS: Autumn@Lezaola-Ins.com East Providence, RI 02914 INSURERS)AFFORDING COVERAGE NAICIM INSURER A: Selective Insurance 12572 INSURED INSURER B: Selective Ins Co 12572 T&J Construction, Inc INSURER C: Selective Insurance 19259 223 Don Ave INSURER D: East Providence, RI 02914 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 95966385-172647 REVISION NUMBER: 46 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 SUER POUCPOLICY NUMBER (MM DDY EFF POLICY EXP D LT TYPE OF INSURANCE INSD R INSD WVD /YYYY) (MM D/YYYY) LIMITS LT A X COMMERCIAL GENERAL LIABILITY S 2441887 03/19/2023 03/19/2024 EACH OCCURRENCE $ 1,000,000 DAMAGE CLAIMS-MADE X OCCUR PREMISESO(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 X POLICY JE LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER. $ B AUTOMOBILE LIABILITY S 2441887 03/19/2023 03/19/2024 (EO eBINdEeDtSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X AU HIRTOSED ONLY X NON-OWAUTOS NENLY D PROPERTY DAMAGE (Per accident) $ O $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C W T WORKERS COMPENSATION WC 9084297 03/19/2023 03/19/2024 X SATUTE OTH- ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 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 E.L.DISEASE-POLICY LIMIT $ 500,000 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth MA ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE I +, 47 1.04:. - f:� 1' (ACH) 01988-2015 ACORD CORPORATION. All rights reserved. Af'f1Rf 9c I9n7RIn'tl The A('ARrl name and Innn arc.reniafererl marks of A('f1RIl Printers hu Ari-1 nn nd/1d/7117'3 nt nV(1f1PMA - . V11.1IFIL ,-c•oc.t. '•4i- ' -^^.4.6400,•;:ti'i_1104-4 11 Ps.,V4iTs4 :1)30-i',"Pele'-'1, T!H--. rG'..,',.•.....i1;4I-r:.)iiiiiii ,! ', - ,'''TAMll,:/.,1(','i,,, 9.7;',AM.A 1.1?,e;el 3TAT 143`..): tt•1iiT • 7.'71! 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Check the appropriate box: Type of project (required): l._ I am a employer with ,r5- employees(full and/or part-time).* 2.11 I am a sole proprietor or partnership and have no employees working for me in 7. [1] New construction any capacity. [No workers'comp. insurance required.] g•�,Remodeling 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9 [I] Demolition 4.1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.❑ Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. I ❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance. 13•El 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 ii I 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: S_j C C ti V,65 _7_"-", S ld_l>Q.,e� Policy#or Self-ins. Lic. #: °- ' q n&it cP 41 -7 Expiration Date: .3r/i / t( Job Site Address: 4-6'4 t? D (Ai, y City/State/Zip: , ,4 / ,&d 1 Attach a copy of the workers' compensation policy declaration page(showing the policy numbef and expiration date).t 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. SiZnat117 � Y l� � 4 Date: Cf /7 .,.) Phone#. LE0/— II T-1 -- 7KV' 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 enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner ofa dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." 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 bum 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 tg 4 — j c)-i Lt)c y4p,y7L,e. 1)-) Work Address Is to be disposed of at the following location: `j(�c� -�f i/ v / 5 T l`AL--Ai•r`0 --' Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 4//?/,2 Signature of Applicant Date Permit No.