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HomeMy WebLinkAboutBLDC-23-13 ' _ pU (Fi�gi2.5 Of•''q,h, BUILDING PERMIT APPLICATION • c APPLICATION TOA CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, S€ i OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. rr ..,.TT� 11«,. .2 Town o 'Yarmouth Building, Department �,,•�.„•",0' 1146 Route 28 • 1•irrnouth, MA 02664-4492 Tel: 508-398-2231 ext. 1161 Fax 508-398-0836 D Office Use Only�j Planning Board Information Assessors Department Information: PBM P 43- /-Ate Plan Type Map // / Permit Fee $ Gor Endorsement Date O 2-- X / -7 d tirn Recording Date New Deposit Rec'd. $ Date Plan No f.4 Property Dimensions: Net Due SC $ ��" Other 71(6)v -- ,5 d 42 4e .g Lot Area(sf) Frdntage(ft) Lot Coverage C lt-#4 2()L)3 This Section for Office Use Only Building Permit Number: Date Issued: Signature: • ,.../: ./ (-,1).')- Certificate of Occupancy Building Official Date• is X Is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: (0`1(- 75?Pt 2fe c, ._viv .. , 1:5 U� 1-- Zonis District Proposed Use 1.3 Building Setbacks(ft) ' %'l ' Front Yard Side Yards _________ . Rear Yard Required Provided Required Provided a R $e6uired TM: , ided 3 b ' lc-' /0' CSu ;)' 1.4 Water Supply(M.Q.L c.40.S 54) 1.5 Flood Zone Information: 2 5 2023 Public y Private Zone. . B _ L_ L NUILDIN '� Section 2- Property Ownership/Authorized Agent c,:Y 2 Owner of Record: s 7 4 tt)7t1/1/4 9A e(print) Mailing Address: Signature Telephone Pe Email Address: 2.2 Authorized Agent ^- ICE c► r<>��,� C�, 7 =1'' S t �� ��oz t (print Mailing Address: _ ,/ 760 cy e il--�-"L-c ,h 4-et i.,• re Telephone Pit' Tess: Emelt Add 1 Section 3 - Construction Services 3.1 Licensed Construetlon Superyisoft Not Applicable -` A' L 1- ISO LS-�1' b 71 I License Number I7 i (C '�1 ` ± 14140r) i-� Address (P t f(71 5 bid 3l t)45 Expiration Date Signature Telephone Email Address: e t Section 6 - Description of Proposed Work(check all applicable)1 ' New Construction ❑ I (for multiple family only) No.of Bedrooms l (for multiple family only) No.of Bathrooms Existing Bldg. ❑ I Repair(s) ❑ Alterations I ❑ I Addition ❑ I Accessory Bldg. ❑ Type I Demolition Other Specify: Brief Description of Proposed Work: Tool- �-Ju5 /d/ I ,t .1 LASI 0 drv(AD r.C;&S Cr/ex-I,' n�l.0 -�f +r'.,. �i ..?-�3_5 �c&.cv, l irk it t.w4< 7 t,�-f- { .�r.rz., ..c" iv rk l..ee;ee ti.z )'" e,,wrrs-- tAALc_ e i d-e.„1 ` v,. ,rl/rite I f 1.i i.- I,,"f,,'lc,,,,c., "3„,„ ,,, _ Section 7- Use Group and Construction Type I Building Use Group (Check as appficapable) Construction Type A ASSEMBLY ❑ .A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ )6 ,s-_--.3 ❑ 18 El8 BUSINESS A-4 A-5 ,,,,,i3 2A ❑E EDUCATIONAL ❑ F FACTORY 28 Cl ❑ F-1 ❑ F-2 ❑ 2C ❑H HIGH HAZARD ❑ I INSTITUTIONAL ❑ 11 3A ❑ M MERCHANTILE ❑ I.2 ❑ 1-3 El38 ❑ 4 ❑ R RESIDENTIAL S STORAGE ❑ S•1 ❑ S-2 ❑ R-3 ❑ 5A ❑ ❑ 58 ❑ U UTILITY ❑ • SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this.section if existing building u ergoing.renovations;additions and/or change In use.I Existing Use Group• Se? ; icZ( r.26L /CI&ILL Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area I • Building Area Existing(if applicable) Number of floors or stories Proposed include basement levels / Floor Area per Floor(st) r 0 , ' ,If Total Area All Floors (sf) � v) E Total Height(ft) 7 Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) I 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, eby authorize .l-�G--y 4 L,4 /,c�/\4Zi J to act on my behalf, in 11- a ers relative to work authorized by this building permit application. L., _________. Signature of Owner ^.).,q. 5 Date • SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent hereby declare trth 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. Ast( -1' / IC /th/ Prin Name nature of Ownerh4 t Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building a Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection �� 7 6.Tota1_(1+2+3+4+5) k , C)�' 7.Total Square Ft.por new smennes&addibms) / Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical • Commission approval (if applicable) 3.2 Register Home Improvement Contractor. Compan�c ems Not Applicable ❑ Ad ess Registration Number Signature Telephone Expiration Date 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"-:4 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 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 tJumber Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor 1 1.1 ":�,����' .+t� .k 'Y �b r SO/U 4../(1-11,S Not Applicable ❑ Company Name Person Resppnsi Ie for Construct n • -) t r-C l-v t H\14iyi, c L. & / Address sC) 3(b -75L/ • Signature Telephone • The Commonwealth of Massachusetts Gi• 1�„ 1 Department of Industrial Accidents 12 1 Congress Street, Suite 100 Boston, MA 02114 2017 Voi Sv , www,mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information • Please Print Legibly Name (Business/Organization/Individual): r ()V- Si)ki--/(.1)2 c- Address: l -j i 1- SI ` lyi r1 f City/State/Zip: AAA (-2-(c;C,/ Phone #: S 0 ;j(v C 75 / 7 Are you an employer? Check the appropriate box: Type of project (required): l.t I am a employer with_employees(full and/or part-time).* 7. 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remw construction any capacity. [No workers'comp. insurance required.] Remodeling — 3._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 property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Ell 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 12.0Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 13•❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14 Other 5(�j/l(J� (,k;0h t --152,§I(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_ 1Contractors 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 nzy employees. Below is the policy and job site • information. Insurance Company Name: 6r. A�� i_ ,_5C- �' Policy#or Self-ins. Lic. #: —MIL) 6G) Q Expiration Date: 9/2.--_3/ 3 Job Site Address: c 7 1 S' V f��, 2g . ., Attach a copy of the workers' compensation policy declaration page(showingCitthetate/Zip:�m • andex ®Z(c, )cj` policy numb and 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. Si nature: __ Phone#: _. Date: - °.S— Official use only. Do not write in this area, to be completed by city or town official . City or Town: Issuing Authority (circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing 6. Other b Inspector 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 V' 8 7 •24/ Work Address Is to be disposed of at the following location: -7)� cL 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. ACcARiffCERTIFICATE OF LIABILITY INSURANCE I DATE(MM/D°""") 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 CONIACI NAME: JIMMY HINDMAN Schlegel&Schlegel Ins Broker PHONE FAx A/C,No,Ext): 508-771-8381 34 Main Street EMAIL (A/C,No): 508-771-0663 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 CENTERVILLE,MA 02632 INSURER D 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 jMM/DD/YYYYL(MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE I O RLN I>D 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 $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ 100,000 A OWNED SCHEDULED AUTOS ONLY AUTOS M1T7484M 02/10/23 02/10/24 BODILY INJURY(Per accident) $ 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- — AND EMPLOYERS'LIABILITY Y/N STATUTE ER B ANY PROPRIETOR/PARTNER/EX OFFICER/MEMBER EXCLUDED?ECUTIVE Y N/A 7PJUB6R08057122 09/23/22 09/23/23 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 — 1 ©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 Relations and Standards Constryteon FS1rvisor CS-107181 E3:)ires:05/27/2025 ILYA LAVREROV 13 BIRCH STREETIll HYANNIS Mile, • , Alt 0.. Commissioner • • • •