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Home My WebLink AboutBLDC-23-38 • • .of.`triiii, BUILDING PERMIT APPLICATION • . - t>f'�� APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, o ,; _ C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. -�� .,.,TT.�.,zt, TownTctrmouth Building Department`•.-.�•",Cd 1 146 Route 28 • Y;inn rttth, MA 02664-4492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 Office Use Only Planning Board Information Assessors Depart ent intormatiea _. Permit1No' I '3. Date Plan Type Map Lot 7 Endorsement Date �� Permit Fee $ )s( � � Recording pate New Deposit Rec'd. $ i) Date Plan No. 1.4 Property Dim Si lei)"�` ,'F t�x,R1 ry 4 NI Net Due $ )�0 .�,,.�.�...;.�.. Other Lot Area(sf) Frontage(It) Lot Coverage This Section for Office Use Only Buildin Permit Number. I Date Issued: ----2,. i Signature: / // Certificate of Occupancy Building Official Date is Is not required Section 1 - Site Information 1 1.1 Property Address: 1.2 Zoning Information:941 KTE6Q �tRt r� St—' 34 04)')4112ninA2"T , MA 076,1 c Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required 1 Provided Required I Provided i 5O 30 I IUD 1.4 Water Supply(141-0.L c.40.S 54) 1.5 Flood jnn�in�r'n�ho -�: Commentx,�;,,,�.1-�, `Public Private Zone: _- '.JC> OE Section 2 - Property Ownership/Authorized Agent Name rint) Mailing Address: `' i-wrr Ctx .1N V atur telephone Telephone Email Address: / 2.2 Authorized Agent:1 Name(prints Mailing 'dress: (.- L NM -. itZ tO 2-c '71 - efizi vs(t,L.,) •cot-1 Signature Telephone Fax Email Address: i Section 3 - Construction Services 3.1 Lleensmd ConstructIo e Not Applicable U (i(o CLAt.4. CAAti r ~IA 1O • )�2 G��>i� License Number / / A dress nil �p�--� ` �S I°G 14 -� v1 c+�/tt \J c 2t 1 1 Expiration D to Signature Telephone rnaif dress: 115 I ��y �ti� f �� tccivk `}'1 G 3.2 Registered Home Improvement Contractar_ Company Herne Not Applicable ❑ _ Lc rZEN rvL cOc c! C2 $ A dress t CO Regittratior4u ti 1 M '�/ 5" 3 6-80 2'i 1 rats _�pOZ F Signature Telephone (Ot4ZLI 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 11&(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 Engineers) a Area of Responsitnlity j OKA—Fitt 'gip -e r ,d c i" rZ ✓ 3C0Address Registration Number C Q 31 Z- 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 o1 Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor Ef W (1S � Not Applicable ❑ Co R�RS arie v. acre_ Peonr onsib f Cons ction ( ►Signature Telephone Section 6 Description of Proposed Work (check all applicable) New Construction ❑ (tor multiple family only) No.Uf Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. cti Repair(s) I. Alterations 51 Addition ❑ Accessory Bldg. ❑ Type Dernolitionl- Other Specify: � I NCI - � Brief D scription of Proposed Work: c - aim C€ &xx(.,01%KV,.. I*3W an-- A NEek.SSeceti u ATE: `tom I JCLv '` ) i<Z b Z I of).- 'RA..TAT-) O- 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 ❑ B BUSINESS t 2A ❑ E EDUCATIONAL ❑ 2B ❑ F FACTORY ❑ F-1 ❑ F-2 El 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-i ❑ S-2 ❑ 58 ❑ U UTILITY r 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: Existing Hazard Index 780 CMR 34 `f'' Proposed Hazard index 780 CMR 34 Section 8 Building Height and Area Building Area Existing(if applicable) Proposed ? Number of floors or stones -2 . include basement levels �.. err Floor Area per Roar(sf) 3 2-50 5 32.50 G - Total Area All Floors (sf) l0! 59,0 sf Total Height(ft) --a 3S cc- Section 9 • STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No. ... SECTION 1 Ca OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR C NTRACTOR APPLIES FOR BUILDING PERMIT I, , CA k - N-3 , as Owner of the subject property, } - `ten 1 P P rtY, hereby authorize �� r " ctei- to act on my behalf, in all matters relative to work authorized by this building permit application. r t Owner Date * 0"sa ? 1-4,-_ `.,g ,x.,,—*-i,:cs,.: g*,o. ,_ _- .sue., ',4. §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 1 1111 1 L-) T (Pc'W e72461 Work Address Is to be disposed of oat the following location: '/N2 tic-14 c1 I PY 1 LA— 'tJ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. . ✓1�1 �rc� ' ,2-12-3 Signature of Application Date Permit No. i The Commonwealth of Massachusetts ► r' (► l Department of Industrial Accidents worm, ; I Congress Street,Suite .I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information C Please Print Legibly Name (Business/Organization/Individual): �.`— (.(t j (i ( (— E-05 Z_ Address: 2...eiqraVot,3 CA City/State/Zip: 5. yNalrka.�!-} C 2 ,t( Phone#: SCY `1116 Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with Citd employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.) 8. Remodeling 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on property. 1 d ❑Building addition ensure that all contractors either have workers'compensation insurance or�are sol I will pI1.2 Electrical repairs or additions proprietors with no employees. 5.0 1 am a 12.®Plumbing repairs or additions general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.; I •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,] *Arty applicant that checks box#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: Pl ot) %NI tX L U A P ( C,(1 ( L eiv' Policy#or Self-ins.Lie.#: 2(-) Expiration Date: ( I ( 1. Job Site Address: 14' (11P1k) St' YireinWirC City/State/Zip: 7 /116' 0261—C Attach a copy of the workers' compensation policy declaration page(showing the policy number 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 penaltiess oof_peduury that the information provided above is true and correct. Sisrnature: T L 2,11 Date: k 1Z \ 'LS Phone#: `g CA d 2 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#: