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HomeMy WebLinkAboutBLDC-23-12 • ` IA Id S Id ' • •• of YAR BUILDING PERMIT APPLICATION • • 2r drQ APPUCATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, 0€„ It C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. E" y Town of-Yarmouth **�««s• `�' Building Department �"- 0 1 146 Route 28 • Yarmouth, MA 02664-4492 Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 •73 Office Use Only Planning Board Information Assessors Department Information: t3Lbe— Z3' ) Date YPe M Permit No. Ply T Lotap Permit Fee $GOO Endorsement Date Q qi Deposit Rec'd. $ . ..,, Recording Date New ate Plan No. 1.4 Pmpyrty tr2ensions Net Due $ 65 Other tot 71s 3 77 -5 1 bi 7.e.- i� i 1 of Area(sf) Frontage(ft) Lot Coverage e Iva 3,0 This Section for Office Use Only Building Permit Number: I Date Issued: Signature: 6- 9 Certfi cpte of Occupancy.. Building Official Date is Is not required Section 1 - Site Information 1 1.1 Prop. Address: r �� 1.2 Zoning Information: Zo District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Required Provided Rear Yard Required Provided Required Provided �L) l 5 -? /t) f 1.4 Water hr(M-a.t_c.40.S 54) 1.5 Flood Zone Information: jr-i.-61 ocome_nbc ,...,, Public Private7 Zone: BFE `-- - -• Section 2- Property Ownership/Authorized Agent] , 2.1 • .r of Records " MAY e, �) `7'C)/k}-r2r7,� �r plg3 i`', 299/ et(print)/ i?IPio ot Mailing s:_ aR7/4ENT Signature Tele hon 1 7 t' 0 .�--_ p e Telephone Email Address: / 2.2 Authorized Agent: /—.1-A4P.C1. 1 6 /Wilily) to ( n t 7 ,� -- , e All Mailing Address: ilk/it-0 c)-)--We ci hAvii 60&V)l, 6 e Telephone S Email Address: j Section 3 - Construction Services I 3.1 Licensed Construction Supervisor 1 , t i I �ke„Joil Not Applicable ( ' ( t•�� t S 62- 26.- 1 License Number Address �V ) Y 0 _ S ) 1 I K) / Signature Telephone ACK0.....ktiI�., rL 00'-aExpiration Date_ Email Addres Section 6 - Description of Proposed Work(check all applicable)I New Construction ❑ I (for multiple family only) No.of Bedrooms 1 (for multiple family only) No.of Bathrooms Existing Bldg. 51:, I Repair(s) 9111 I Alterations ❑ I Addition ❑ I Accessory Bldg. ❑ Type I Demolition Other Specify: 1 Brief Des ription of Proposed Work: r1 t).5. ;2/ ,4: 4, - ip /44 _., Section 7- Use Group and Construction Type I Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ to ❑ A-4 ❑ A-5 ❑ 18 ❑ B BUSINESS 16 r+ t - ) 2A E EDUCATIONAL ❑ ❑ F FACTORY C32B ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ I INSTITUTIONAL ❑ I t 3A ❑ ❑ 12 ❑ 13 ❑M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL 4 ❑ S STORAGE ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ u UTILITY � s-1 ❑ S-2 ❑ sa ID SPECIFY: • M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this.section if existing building undergoing renovations;additions and/or change Iri use. I_ ` t/' Existing Use Group: ) Lc_- �• l J5 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 f Floor Area per Floor(st) /I ' , Total Area All Floors (sf) Total Height(ft) f 15 Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) I Independent Structural Engineering Structural Peer Review Required Yes No l 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 .-{A- LAVjoijim to act on (my behalf, in all a ers relative to work authorized by this building pen-nit application. - 5-: z . I-3 1/4),e/C/,Signature of Owner Date r , . SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION • I, 4L ' /<- '71 / t 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 ooff�perjury. ' .VOL-"V.-A----k-/ i / iri/n-i--1 i.'- . • Print Name � ._ Signature of Ow gent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building 61-6C;) 2.Electrical 5jpV 3.Plumbing I Gas .° 1) 4.Mechanical(HVAC) 5.Fire Protection )� -^'(�\7/ _.-•- 6.Total=(1+2+3+4+5) • r/ i 7.Total Square Ft (lanew smcnires a add fiau) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) 3.2 Registered Home Improvement Contractor. Company Hama Not Applicable D Address Registration Number 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 F(__ Not Applicable 4 farn�a (Rsgi traatj: 4J-t- 0 ��f, ,,Af c, s y Registration NumberAd refs ���111i���_""" ,,, ,/ ' �gj�1'✓ �L/, I�r ���t;✓a.�-r�(:�\�jG�( �+(..�"1/+'� v' Expiration Dat ) Signature Telephone ' /'' 2,3 Section 5.2 Registered Professional Engineer(s) Nam. Area of Responsibility Address Registration Number Signature Telephone Expiration Date Hama Area of Responsibility Address Registration Number Signature Telephone Expiration Date Hama 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 €"` Lr So ( Not Applicable ❑ Company Hams Person Responsible for Con tructi n 5 Address - ,„_t 3 -75 Signature Telephone �i #-- COMMERCIAL ONLY- BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: ‘9 LI- B 28 PI z3 65,4?„-- Scope of Proposed Work: -% q K,-- rz-- j, kkl 164// 5 (i) o +h (CC Y `fit) Sluii"1�✓{-tc-�'/(JZ /,L �_.it. -u--‘,S 1 4 /G.r UYCi l'h(1 V _ / l,,v t /' �y`1 U�, j it, ' cl ik i/ Gt -2- t)+=i l k IA)/ a tr / J ui � 6 E7406i i 54 Date: 6 2-3" Z V 4.e'l% +_-ee, v.-Uzi-6 iti.ti-X) &Ai)fri ctS kr),L i- 01.1 v‘i 5 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. Receip owl d nt: _ 1 5 ) 'I-)9 Applicant's Signature Date Rev. March 2022 • 1 � • The Commonwealth of Massachusetts It Department of Industrial Accidents 1 Congress Street, Suite e 100 Boston, MA 02114 2017 ..s .www,massgov/dia tir Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ..)4-67/044/(0 E51-f-/-t_e-10-"V" S-6-10---p_T- Address: ! 6) ran 54' City/State/Zip: -/-1-1/10-71 /I , S Phone#: 5-og 3 O 7 Are you an employer? Check tEe appropriate box: XType of project (required): 1. 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 ❑ New de15truCtlon any capacity. [No workers'comp. insurance required.] 8. emoling 3.—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 my property. 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.❑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.] 13•Ea'oof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14 ether 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: 5e_..I\_je.— ` ''JJ Policy#or Self-ins. Lic. #: , I xpiration Date: 1— 2,3 d 23 Job Site Address: '2 7 r eY75 Q f-Z �'Attach a copy of the workers' compensation policy declaration page(showing the policy nuate/Zip: er a d expiration4 �). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,5 0 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: 3----_ ZL ,2_3 Date: T' Phone#: c--0 - 3(v , 1 7,S 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#: 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 C3 6J 2g ' 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. r� I Signature of Applicant Date Permit No. ACoRt1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 NAONiACi ME: JIMMY HINDMAN Schlegel&Schlegel Ins Broker PHONE FAx 34 Main Street (ac,No.EXtI: 508-771-8381 (A/c,No): 508-771-0663 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 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 (MM/DDIYYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED 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 AWNED AUTOS SCHEDULED accident) $ 02/10/23 02/10/24 BODILY INJURY(Per AUTOS ONLY M1T7484M300,000 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 ANY 101 OFFICER/MEMBER EXCLUDED?ECUTIVE EACH ACCIDENT 100,000 Y N/A E.L. (Mandatory In NH) 7PJUB6R08057122 09/23/22 09/23/23 $ 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 ©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 VI Board of Building Relations and Standards ConstrytiltonrSikervisor CS-107181 I 1513ires•05/27/2025 , ILYA LAVREOOV 13 BIRCH STRE- , • / Aft • HYANNIS •• i, 4‘0.1...EvaN3 Commissioner rt • •