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HomeMy WebLinkAboutBLDC-23-37 r • ..oF:YAR BUILDING PERMIT APPLICATION ' • '3p APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, 'o ; i — OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. MATT.!11«, �' Town of'Y:umouth Building Department T•••-y,••" l 146 Route _N • Iarmouth, MA 026644-192 Tel: 508-398-2231 ext 1261 Fax 508-398-0836 — {-, Office Use Only Planning Board Information Assessors Department Information: Permit No. % Date Plan Type_ Map Lot (^0,Cd Permit Fee $ Endorsement Date r, f ��� ( Recording Cate Deposit Rec'd. $ ;f r Date / Newew • 0Plan Na._ 1.4 Property Dimensions: Net Due $ Other Lot Area(sf) Frontage(ft) Lot Coverage This Section for Office Use Only Building Permit Number: ,�' Date Issued: Signature: ) �, � � Li -3 . Certificate of Occupancy Building Official Date• is Is not required Section 1 - Site Information I 1.1 Property Address: 1.2 Zoning-Information: - /20 LT Zz r Zoning District Proposed Use 1.3 Building Setbacks(ft) • Front Yard Side Yards Rear Yard Required Provided Required Provided Required q I Provided 1.4 Water Supply(M.Q.L e.40.S 54) 1.5 Rood Zone Information: Comment= Public Private Zone: _ BFE • Section 2 - Property Ownership/Authorized Agent 2.1 9weer of Rec rd: / N N/�/�Fylf;3r�/LRO I f — (\ t�>t ftr1 titer a ,e(print) i Mailing Address: Signature ` ele h ne Tel phone�_C Email Address: 2.2 Authorized Agent:J,, e'c`—' — /0J /->~41,- > i ZR 1 r+-L `iitei(4,3- e)rfis e / (p Mailing Address: I` : %- It- SIC%i , igna re, Telephone Fax Email Address j Sec on 3 - Construction Services 3.1 Icensed Construction Supervisor. Not Applicable ci u , _/ AA License Number Address6-4S1 .� -- pi 9� /? -�`' — s_— ---- ExpirationDate Signy re 1,,.-`' Telephone Email Address: 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) 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 0 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 I Not Applicable ❑ Company Kama Person Responsible for Construction Address Signature Telephone - SECTION 10b OWNERf AUTHORIZED AGENT DECLARATION C--)'- ; t .S` e ` , 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. 4-IA.. e Print N. _ Arfror AY Date �. _ re of Ow n II Pr Section 11 - IMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permt:applicant 1.Building 410 2.Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection 6.Total=(1 +2+3+4+5) 7.Total Square Ft.(Ix new seucanes&aadiitima) Check Below 0 Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) ' : f ' • . Section 6 - Description of Proposed Work (check all applicable) New Construction 0 (for multiple family only) No.DI`Bedrooms 1 (for multiple family only) No.of Bathrooms Existing Bldg. ❑ I Repair(s) ❑ l Alterations RI I Addition ❑ 1 Accessory Bldg. ❑ Type I Demolition Other Specify: P fy: I Brief Description of Proposed Work: 2t4 a`.e ✓ b..r,06 2 CY.,t iitt A-C4"› ry: ;-t. , Ac4-c'' '/Z.- lk S/4-4-4._ '..et., j 1i( :i-1 pti-jTrl, 4A.k=1-1, +2.147,,r.:7-r.7s ,t ,..,,:r3 s.�tc, - }..u-. /lh3u." .,.4.0.1..) ow_-:.;.7 isilf-4a ,4J;4) fhe;,� tilsiV`:, ;� � S,.MI�L PL 1) c jt, 1 1. l./ z7 Section 7- Use Group and Construction Type ;r Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A_1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL ❑ as ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M MERCHANTILE 0 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 0 R-3 ❑ 5A ❑ S STORAGE ❑ S-1 ❑ S-2 ❑ se ❑ U UTILITY 0T 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 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 (78OCMR 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 I \• _, , as Owner of the subject property, here tol `t -,t �4.4._, to act on my pehalf, in-all.,matters(l�r�l'ative to work authorized by this building permit application. cS, re 't, „. Date • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 I I' Boston, MA 02114-2017 5�• www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): C � t jci.ek '1- • Address: le)I' f(. z 7'F ij :,u9 Di�� City/State/Zip: � � S16- Phone #: M5 - IC Are you an employer? Check the appropriate box: Type of project (required): 1.$I am a employer with employees(full and/or part-time).* �"�• 7. El New construction 2.—I am a sole proprietor or partnership and have no employees working for me in ca aci 8. emodeling an y p ty. [No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. t 9. _ Demolition ❑ y [No workers'comp. insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on m property.Y I will 10 E Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp. insurance.1 1 •El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4.❑Other 152,§I(4),and we have no employees. [No workers'comp. insurance required.] *Any 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: /4, oliz �- r Policy# or Self-ins. Lic. #: r• Expiration Date: %r "= 0'i, Job Site Address: // 1 )(5j City/State/Zip: S. ccc;�l, Al 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 cert. un r th pa' s enal ' s perjury that the information provided above is true and correct. Signature: Date: Phone#: 57513 - f©o 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#: 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 //, Work Address Is to be disposed of at the following location: '*<; ( jI Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111,,,Section 150A. Signa ur of Applicant Date Permit No. 80.0scMf0.'OMDIW[N� ill {6@:T(#Claf40QND1lp�R • i\ il El‘'. Pq 1 MEd 1 ININ tMIN C( INN ri ' ' iIIM \ ''D d 1- 1 \ a uw tainnoorowo E 1 O. 1 k \ 1 / 1 6/' -- - '0 ' - ' ---0 / -1- - '.-A 0 / ► '1. Ci LOWER LEVEL FLOOR PLAN SCALE:3/8"=1'-m I i ...re —_r9 — E7710DtCf4C1"3 WNW UHR..�, c �• 4 '7 I on ,, '- }'.,.,• 1 rg'Zig DM!- ! l am. , , ri y D wDfOCfirgib7 7'" t ! 1 BATH { , TARS*rn:men.,mRun\� J l \ 1 1 //t^'_ _. _- i I Cr � ,S107p,DIX:SfV 1, / I— / 1 i r _ i � E / per/ ( I � I ( y j CAI MS o ,Yi� I I 1 I .'1 ti 1 �---1 1 1 J 1 \ , ..r. 1 w� ' (..... 3n rnooana —� i S S CDDAfl.;AL 6. iDTlODR i H. 41. ` �111 b � mom po1!_DtaDIWM / fO,R • , r edvfL a •�Y tort QIomenta:AR°nevi erwrimpinimins 6 13'8.3Jt1 r. ( t SHOWROOM STREET LEVEL FLOOR PLAN SCALE:318"w 1'-C" LE -:EZ -;;(77E 21' 11" SHMIROOM STREET LEVEL FLOOR PLAN SCALE: 30' = V - 0" 26 7" aF laeeRa owrwER � 1 j � � .t I /p n 1 �,.., f ff 1 1 I I { i � t � I ! ! { LOV\ ER LEVEL FLOOR PLAN SCALE: 3/8" = V - 0" SCALE 10 FEET 0 10 N M 8 z ot mi Z a` i 0 0 N J } N6 CAD BY: BD 5 JULY 20M CHECKED BY: sent!=:8 XII-8" ft.A-1