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HomeMy WebLinkAboutBLDC-23-47 f . t vJ L 1 LA f i,✓"` `y, ,• .0 t,'� tAdi r/✓ i'4'fr \✓✓r/ r . , of•YqR BUILDING PERMIT APPLICATION • . . ... 4r, APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, ,S'4, e ii OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. 111 ,Z.' Town of-Yarmouth Building Department `'�••'t••",@' 1 146 Route 28 • Yarmouth, MA 02664-4492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 - Office Use Only Planning Board Information Assessors Department Information v Map Lot Permit No.d��l 0G'� ' Z.��ate 9! Plan Type Permit Fee $ 7;)C; Endorsement Date / Recording Date New Deposit Rec'd. $ 60 Date plan Na. 1.4 Property Dimensions: Net Due $ I) 0 Other Lot Area(sf) Frontage(It) Lot Coverage This Section for Office Use Only Building Permit Number Date Issued: Signature: S1/4//• Certificate of Occupancy l 'iiI • / ing Official Date is is not required Section 1 - Site Information �/1.1 Property Add iffrest,,:jj`� 1.2 Zoning Information►S f .LF—.' (x.8 i �{ yacJlI' r 1 P (I)GO-I Zoning District Proposed Use 1.3 Building Setbacks(ft) ' 1 •; it Front Yard Side Yards Rear Yard I to Required Provided Required Provided, Required Provided 1.4 Water Supply(M.tl.L c.40.S 54) 1.5 Flood Zone lnlorma' 2I 76 comments Public Private Zone: F416 ' () LIi/3 Section 2 - Property Ownership/Authorized Agent �' 2.1 Owner of Record. Name(print) Mailing Address: l Signature Telephone Telephone / Email Address: 2.2 Authorized Agent x_Y-)'‘Ok)C(.1 i•'0. , f'yNk '.\C)i"- --`-:,-- U:t4C ems(print) / Mailing Address: 100( - i?CI ( I '044- , (-.C:i'ill'---'' . Si attire Te le hone Fax Address: I Section 3 - Construction Services , 3.1 Ucen Construction Supervisor Not ApplicableEmai g] /�, rof ,-• t r635 License Number [4,-(404 Lir?/ Ca Address Expiration Date Sig t Te ephone Email Address: . Section 6 - Description of Proposed Work(check all applicable) ' New Construction ❑ (tor multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. . Repair(s) 0 Alterations D Addition El Accessory Bldg. ❑ Type Demolition Other Specify: I Brief Des rip+ipn of Proposed Work i 9 r -Y 5 : Y f ..r _�c r. .f i f%c.t:.. { �� �C i, _ �i rer1 :; 4 r i 0,- '..:.) r ' ' , " .c� I' ' i vex. art'1) C, ,L'-'`'s I, Section 7- Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type A ASSEMBLY 0 A-1 ❑ A-2 ❑ A-3 ❑ 1A 0 A-4 0 A-5 ❑ is B BUSINESS ® 2A E EDUCATIONAL ❑ 2a F FACTORY ❑ F_1 0 F-2 ® 2C H HIGH HAZARD ® 3A ❑ I INSTITUTIONAL 0 I-1 ❑ 1-2 O 1.3 D 3B ❑ M MERCHANTILE 0 4 I] R RESIDENTIAL C) R-1 0 R-2 0 R-3 ❑ SA ❑ S STORAGE ❑ s-1 0 S-2 ❑ 59 ❑ U UTILITY C) SPECIFY: _ M MIXED USE pSPECIFY: _ S SPECIAL USE DSPECIFY: _ Complete this.section if existing budding undergoing renovations:additions and/or change Ili 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(ii 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 as Owner of the subject property, hereby authorize 4.42,t o Z1 (:;:-6 Sri .1'`') ,r to act on my behalf, in all matters relative to work authorized by this building permit application. Si natur of'Ow 4r — Date SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION I, IV! /.i-' ,. , as Owner/AuthorizedAgent 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. .�� �' /f i)('Ijyr h(R / or,,1 �hkc- 4 f'/of P t Name r _6 7)7< t9,411 .`t J �) �r(9 c I, far, Cx;' of Owner/Agent / t Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item ' Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2 Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection 6.Total=(1+2+3+4+5) f10 7.Total Square Ft(rornaw MOMS&additioml Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) . , . . . 3.2 Registered Home Improvement Contractor:.1 . , Company Name Not Applicable ID , Registration Number r=-c‘0 y• , Cr 1 JAI ft;2.- , ,),'" :.;:' Expiration Date 1 Signature /- /1/ Section 4- Workers'Compensation Insurance Affidavit(M.G.L c. is?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 he issuance of the building permit. Signed Affidavit Attached Yes No 1 . 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:I Not Applicable El Hams (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer(s)1 Mame 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 S Telephone Expiration Date Section 5.3 General Contractor fr ' Not Applicable El--)n.lt:// ,',._:,1--7„, ,1,2-`','.:3CSir 2)')C Company Hams --- -- - ' ,,' &Kt.,/ - 01," Pergp Respopsible 19t Constn;iction A, 1 -'? -,2, 1 c _..., ---, r? //+ ' 7 . ... .., Telephone - Si— ii- ,'9 • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ..S�•`�v www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Brtcr\ou Error] s>1.(6e r iJC. Address: 4c2 /M/ef10R L1q j6 City/State/Zip: CQTO/T 7n4 OcX35Phone#: ( (J4)66 j—q.J06 Are you an employer? Check the appropriate box: Type of project(required): 1.Z I am a employer with a 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.:I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. Demolition 4.❑ my property.I am a homeowner and will be hiring contractors to conduct all work on I will 10 [] Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.D 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.t 13•❑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#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. Insurance Company Name: -A f \ � Pa e idiA t-c\3 CO • Policy#or Self-ins. Lic. #: G H U BOG. ui s3d3 Expiration Date: 20cc1 Job Site Address: b01_ Re, 09.2 City/State/Zip: 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: (�� (� Date: 1 _' Phone#: - L11 0C Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone#: Contact Person: TOWN OF YARMOUTH OUT. 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G. L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5 I hereby certify that the debris resulting from the proposed work/demolition to be conducted at i .A-izRDt. -IA' TO uz, a) 2O .M P - Work Address Is to be disposed of at the following location: VA rZ.v ��,/ �! °ct��t1 �° ``, Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 44' Signature of Applicant Date Permit No. s"6 �` ,,, y.,s"'3;;,[sN'„' iiw%�Yi, 1%i1, '.,! r�° �,w"' -k„,'a' Y.2•X�E,. 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' I pol uu i• ' IUNIT TYPE 't : .f E LI ROOM ,,BEDROOM tM.A$TE B of o ; 4. - N„,,,.. 4„,,, . .. . : _..........7— NT— '--------— 410410""L".41r.".11211=2, -- .4"0""""""rt-,440M11040. =Usam— ., w—'n—4 W x, ».,,. ... 4 ..r w.w ar Unit' Ewa «,' - .• L .,....:„,,,:,;.:..,,,,,,, ,,5:,.••5•6•74:-.:5'5,;•"'5•,',.;.;.R:.". '.',:Al: • Fh 6%' • g%5•° A D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) ,.r 06/17/2023 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 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 Benson Young&Downs Ins CONTACT Carl Goveia NAME._....__............._.....................__.vein - ............._._.----...--- 56 Howland Street PHONE Fxr)• (508)487-0500 (AJQ No): 487-4135 PO Box 559 EMAIL carlgoveia@BYandD.com ADDRESS' Provincetown MA 02657-0559 INSURER(S)AFFORDING COVERAGE NAIL# INSURERA:Atlantic Casualty Insurance Co 42846 INSURED INSURER B;Arbella Protection Ins Co 41360 Bronov Enterprises Inc INSURER C:Travelers Indemnity of America 25666 72 Anchor Lane INSURER D_ I Cotuit MA 02635- INSURERE: ._._.__...._.......__.-- —..._...----�.......----.._--._._._— I 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INnn wvn POLICY NUMBER (MMIDOIYYYY) 4MM1DDIYYYY� LIMITS A X COMMERCIAL GENERAL LIABILITY M2050018110 07/02/2023 07/02/2024 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED 100,000 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MEDEXPIAny_one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY i JE� _—_1 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER; $ B AUTOMOBILE LIABILITY 1020102822 12/29/2022 12/29/2023 COMBINED SINGLE LIMIT $ (Fa accident) ANY AUTO BODILY INJURY(Per person) $ 500,000 ALL OWNED '', X SCHEDULED ._..__ AUTOS AUTOS BODILY INJURY(Per accident) $ 1,000,000 X 1 X NON-OWNED PROPERTY DAMAGE $ 250,000 HIRED AUTOS AUTOS .(Per accident) I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION 6HUBOG14209323 07/03/2023 07/03/2024 X_MUTE ERH AND EMPLOYERS'LIABILITY N 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y N!A E.L.EACH ACCIDENT__ $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE_EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Carpentry&Remodeling Operations and Cleaning Service. OFFICER OLGA BOCHKO IS EXEMPT FROM WORKERS COMPENSATION INSURANCE POLICY CERTIFICATE HOLDER CANCELLATION Al 008861 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 SOUTH YARMOUTH MA 02664- AUTHORIZED REPRESENTATIVE 0,9 Fax:(508)398-0836 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • THE COMMONWEALCH OF NIASSACHUSETTS fr . Office of Consumer f rs and Business Reguiation 1000 nStreet-Sui Boston, th ss s 02110 Home Improvement Contractor Pggistration Typo: CorporatiOn Registration: 182479 ENTERPRISES€C Expiration, 06125/2025 72 AtiltetiOR LANE COTUIT, MA 6 r UPdate Andreae . end Fiction Cord,. THE COMMONWEALTHOF MASSACHUSETTS Office etacineutrier AtifjOes Si Bulginess Regulation Registration valid for Individual tise only before lila HOME MOOFKARItegfet CONTRACTOR expiration data If found return to, Office TYPE:Corporation of Corieureer Affair,arid Easinessis 1000 Weaningfon Street Suite 710 182 479 06 Beaton,MAt 8 BFiONOV ENTERPRISESINC 72 ANCHOR LANE COT I'7,Mfg OPe35 &Jnd rsocretar" Net/Valid without signature a.* � � � Meierg y 7y /�iirr Ciorr • p n COMMERCIAL ONLY- BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE • Address of Proposed Work: Ls k '. \ ),. w. c 0, \,.,().l i Y i : r r 1� , i '' i' Scope of Proposed Work: I t', _ } ,�, Kai 1<!,_(1/4.. , c, ,r,,, Ji),\I, ,c, i?)ki-',AL 0(rt•-cr 1 ,-, \--,(r -ir;--in 0,11, 1.6 rr,,At., ,..,As.,--,,,, f," 7-4r f-,,,,_ .:,`...,it;'4 Date: ' q',~ '.�° f _..)% 11 .�% Based on the scope of work described above, the applicant is required to obtain approval 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. Receipt Acknowledgement: Applicant's Signature.— /'_.,, 2 Date 000//z ? T3 Rev. March 2022