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HomeMy WebLinkAboutbldc-23-9 Unit 19 • I ..• , • • of•1'444 BUILDING PERMIT APPLICATION ��� O tr APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, ra f,o .,gm C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. ~_ 0 ,.. i 'f try �' r�. Town of N'armouth Building Department 1 146 Route 28 • Yarmouth, I� • • c JUN 13 I '` — � Tel: MA O_(�b-1—t•-iJ? 50�-398-Z23i ext. 1261 Fax 508-398-0836 ;r ' ,,f r,n, r,'N ' ice Use Only Planning Board Information Assessors Department Information: L- Date Plan Type Map Lor 0 Permit Fee $(n O Endorsement Date 0 2--$// Gi l tg ,i Recording Date v Deposit Rec d. .. e New r / Plan No. 1.4 Pmperty Dimensions: Net Due $ 6 ) Other - c ���`� � '' Lot ea id) Frontage in) Lot Coverage Building Permit Number: This Section for Office Use Only .�-� 1 Date Issued: Signature; /, ��J .� Certificate of Occupancy- Building Official - Date is X Is not required • Section 1 - Site Information If 1.1 Property Addrs 4L 1 I1.2 Zoning Information P2- it i eik C: . Zon' g District Proposed Use 1.3 Building Setbacks(ft) • Front Yard Side Yards Required Rear Yard Provided Required Provided Required Provided 1.4 Water Supply(M.a.L a 40.S 54) 1.5l '� �Ci�� t� FloodZonshdc.,,wtR„y Comments Public V%- Private Zone: SFE: • Section 2- Property Ownership/Authorized Agent] 2.1 Owner of Record: (--tcc:,,d P i'ri,01E-0 n i 67 //- A.--er-5F6-iitt,,,,,i/11. 622_732 Name(print) Mailing Address: Cq Signature Telephone - F-. 7- " _ a te- u r 7/116-1 ✓rti ZtiYv/,2/:. 2.2 t7 Email Address: I Authorized Agent:j a � . MAY 25 2023 7( 6z' ,-1 t . 4U__ 1�7p / o t i3U11 ;).14 t-_i'w ll IV C_�_e/� 7 t i _ ;.Maiing Address: rJ j0 YA✓/mot 6 ig - ure Telephone -Fax- Email Address j Section 3 - Construction Services I 3.1 Licensed Construction Supervisor: Not Applicable Cl L>1A- LA V ,1 ;i- / CS ---7 d 7/P/ _ i� l 5 � License Number Address7fii/7/ --N ,) da1 I �.pyi , ] Expiration Date Signature �,�p Aevz4e, ' `' �'��J `I�elephone Email Address:��( J: Su r.4 _ 3.2 Re eyed Home Improvement Contractor. ` , Com ny Name Not Applicable ❑ Registration Number ddress / Exp ration 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 1 rULk L Pro 0 I r Not Applicable ❑ Name (Reg III Aver t I' A t In I(�,o . / Jt,l !(o } Registration 4i s' 7 Addd�sly ()r b-b144l �(��Z ( (±i 5 U 5 f' OC��1 Expiration Date z Z Signature Telephone 15/1 --.2 Section 5.2 Registered Professional Engineer(s) Area of Responsibility Hams Address Registration Number Signature Telephone Expiration Date Area of Responsibility Name . Address Registration Number Signature Telephone Expiration Date • Area of Responsibility Name Address Registration Number Signature Telephone Expiration Date Name Address Area of Responsibility Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor I A-( irc. 4-,-et Vt'5 I Ufltm S Not Applicable Cl Comps ve.eA)0 V Person spoptsible forCo ction tt'LllY\1iA14r 2V)1 Address Q 51)%3k'D �1`75 ti V� Signature Telephone Section 6 - Description of Proposed Work (check all applicable) `, New Construction ❑ (tor multiple family only) No.of Bedrooms (for multiple_ D family only) No.of Bathrooms Existing Bldg. ►` Repair(s) ►I Alterations ❑ Addition El Accessory Bldg. ❑ Type ( oIition Other Specify: i Brief Description of Prop"osed Work: 'Jt ye ,� (4 5 P &i- tJ-1---,I-s a ,,k-Q-U--e q ( . - el ) i r!,-&p )-2-il 65734,,k. (6blij, Coy-vc.,r,-ckt_ (:c.kyr:1 _5 Section 7- Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type • A ASSEMBLY ❑ A_1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1 B ❑ 3 BUSINESS -j Z v ', 2A ❑ - ` E EDUCATIONAL ❑ F FACTORY 2B ❑ ❑ F-1 ❑ F-2 ❑ 2C 0 I-I HIGH HAZARD ❑ 0 3A I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 38 M MERCHANTILE ❑ ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S STORAGE ❑ S-1 ❑ 3-2 ❑ 5B ❑ U UTILITY ❑ _ SPECIFY: . M MIXED USE ❑ SPECIFY: S SPECIAL USE 0 SPECIFY: IComplete this section if existing building undergoing renovations;additions and/or change in use.I_ Existing Use Group: elx-�'7i'T Nat yr',,,Q 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) ,'OO 1 / Total Height(ft) 4 1 / , — 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 l �f L) 2,Jo_) 7 , as Owner of the subject property, hereb authorize �v i 4 ��(JI`-' to act on my •-or-.-If, in al a rs elative to work authorized by this building permit application. #j S.'Z1 Date Signature of Owner r ' , • • SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION I, v761-' '(iv:Z i- P/ j /G v'7y2, /t 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. t r cf)4 Print j / 2 Signa re of 0_ er/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2 Electrical 3.Plumbing/Gas it 4.Mechanical(HVAC) 5.Fire Protection • ✓ _ 6.Total=(1+2+3+4+5) Y I,L,(5L.) 7.Total Square FL(larnaw,smcsma&additions) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical • Commission approval (if applicable) COMMERCIAL C)NLY- BULDING PERMIT C APPLICATION REGULATORY APPROVALS NOTICE -Et 1 ' Address of Proposed Work: cYC)L('' Y M ej 2A Scope of Proposed Work: /1 /'' /PJ-(' v /k4 i,.64-.4-,Ac ,c1,j / Jca Uri 1r -. 11.(4,�t-t � -, e , " Date: 2i] -z`/ Based on the scope of work described above, the applicant is required to obtain approval 4 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. Rec- ,t Ackn dge nt: ___S-70,2- - a9 0-? Applicant s Signature Da e Rev. March 2022 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 s"'S 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): 4C -A-ett .f icr Address: 13 61'ral . City/State/Zip: q h n S D24 b I Phone #: 50g 3 b o 7 sy Are you an employer? Check the appropriate box: Type of project (required): 1.12II 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.. ❑ ReRem delinruction any capacity. [No workers'comp. insurance required.] Oeling 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 my roe 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.i 13• Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14• Other P-_ fC& ri/ ` 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. rr Insurance Company Name: ,A. I Q C q`S C h Policy# or Self-ins. Lic. #: s. o D �+ ` 7�� Expiration Date: y— 2 _ 2-3 Job Site Address: 4 -1- b Zg City/State/Zip:55 C ✓`'l l Attach a copy of the workers' compensation policy declaration page(showing the policynum4 r 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. Signature: Date: tj " 2-3 `Z/ Phone#: 50g 3420 17 .5 y 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 of-a 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 ` O '`t5ir Q-A/ Work Address Is to be disposed of at the following location: Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signature of Applicant Date Permit No. Act)/Re CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD""'") 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 PHONE,Ext): 508-771-8381 FAX (A/C,No): 508-771-0663 34 Main Street E-MAIL 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 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 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 $ DAMAGrl O RtR I ED 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 AUTOS 300,000 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- STATUTE ER AND EMPLOYERS'LIABILITY Y/N 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) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 ©1988-20 5 ACORD CORPORATION. All rights reserved_ ACORD 25(2016/03) The ACORD name and logo are registered marks of ACO Division of Occupational Licensure Board of Building Regulations and Standards Constottilion fS ervisor CS-107181 i f Fires:05/27/2025 ILYA LAVRE z V �' ; ,+ � ;� 5 l 13 BIRCH STREET ,i I jp � • it HYANNIS MO rya 4OJjvdi1 D` Commissioner • • • " r