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• •• oe•Y.9,4 BUILDING PERMIT APPLICATION •
• . .�F $ APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF,
• l€;; C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Y � y Town ui \itrmouth Building Department
�,~�"....; 1 146 Route 28 • = t 2 _ �.,.. •:
Yarmouth, MA()?(iti-l-E-fJ_ � � ' �''
Pau
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836' _._.--
Office Use On ' -i OnlyPlanning Board Information Assessors Department Information ittN 2 ��J
Permitiga? 2--3-
g Plan TYPe M ��u,rvc� [�E~ti�AR 1� t��i
Endorsement Date
Permit Fee $ Co t? ��' _
Recording Date New
Deposit Rec'd. $ 00,( ' Date Loa_ Plan No. 1•4(' rn Dime 'ons %'
Net Due ke l IZ ,3C1 =� k` 7 S
S Other Lot- (st) Frontage(tt) Lot Coverage
U.,' as L'I r- This Section for Office Use Only
Building Permit Number I Date Issued:
Signature: • ,. -----> C-, )-A3 Certif ate of Occupancy.
Building f icial Date is Is not required
Section 1 - Site Information I
1.1 Property Address:
�� 1.2 Zoning information: f� /
5c,Lt -e78 42 2s Q� 1)� 1
Zone g District Proposed Use
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.4 Water Supply(M-n-L e.40.S 54) 1.5 Flood Zone Information: Comments •
Public / Private Zone: ' BFE:
Section 2- Property Ownership/Authorized Agent I
2.1 O er of Recce : // ``��
' 4-LLI-'7444
a �� �f (,f7 '3ggl)E,
Mailing Address:�gnature Tele j b'•r-...-E l"�`'/ <c�Ve-(//ZL1�.
Telephone Telephone /, ,
Email Address: Y-
2.2 Authorized Agent
r (-7 ,C>>i-x,i ; Lb`7 to --
nt) Mailing Address:
I7(etit"' .31) V �r�r. f )( O C r!-
ig toe Telephone
Email ddress:
Section 3 - Construction Services
3.1 Licensed Construction Supervisor: Not Applicable ij
Icy `r iAv-e i/Vo ( A c /0 7 i g l _
/ .5 B I a rs 4 ,y �17Oj License Number
Addre f 1 I /*71v , 11 i"�fcJ (��- j -- 7 -. 5
N.......f.„
• ---c(3g3(0° )159 Expiration Date
Signal re Telephone Email Address:
, ♦ t
Section 6 - Description of Proposed Work(check all applicable)I
.♦ New Construction ❑ I (for multiple family only) No.of Bedrooms l (for multiple family only) No.of Bathrooms
Existing Bldg.lid I Repair(s) a J Alterations FS' J Addition ❑
Accessory Bldg. ❑ Type I Demolition Other Specify:
peci fY:
Brief Description of Proposed Work: , J
Y 7) / 9 j
Pi ' - 0--)4 4 /- i HOry 4 a C; -W 17-e_a ' Pw/gp 0 0 -
cAiiw Ci cdi- .4-ce2. OA. J i t.)-31 -ay,,,Dcyviq'yKe:-/) o-17 / A_k____
u3I cyt Inc►ck- (a=)9 f"4. Ave, )l y fz-s, /lc,,;..
_)
Section 7- Use Group and Construction Type
J
Building Use Group (Check as applicapable) Construction Type
A ASSEMBLY 0 A-1 ❑ A-2 ❑ A-3 ❑ 1A 0
A-4 ❑ A-5 0 1 B ❑
B BUSINESS bp"�`, ( -tic 3 2A ❑
E EDUCATIONAL ❑ ❑
F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD 3A
El
I INSTITUTIONAL ❑ I-1 (3 1-2 ❑ 1-3 ❑ 3B ❑
M MERCHANTILE ❑ 4 ❑ -
R RESIDENTIAL 0 R-1 0 R-2 ❑ R-3 O 5A ❑
S STORAGE CIS-1 0 S-2 ❑ 58 ❑
U UTIUTY IDr _
SPECIFY: •
M MIXED USE El SPECIFY:
PECIFY[
S SPECIAL USE
S
j Complete this section if existin building undergoing.renovati s;additions and/or change in use.I
Existing Use Group: „i k Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area
Building Area (sting(if applicable) Proposed
Number of floors or stones
include basement levels fff/
Floor Area per Roar(sf) / .
Total Area All Floors (sf) /60 5.i I1 i
r
Total Height(ft) /
Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 1 Oa OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNER'S AGENT O/, i CONTRACTOR APPLIES FOR BUILDING PERMIT
I" ----e e J 1) /m// f) ) , as Owner of the subject property,
her author' 1 CIS(%"l ( to act on
my b If, in I m relative to -- rk authorized by this building permit application.
Date
Signature of Owner
r ' _
SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION
I, - P Cs? , as Owner/Authorized Agent
hereby declare that the stdtements 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.
• (—A C? en/1/1-v\,v) (
Ff. N e
' a e o wner/A ent 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) (�i(aJ
7.Total Square FL Ira new smcanes&amiho,el
Check Below
❑ Conservation-Commission Fling
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
3.2 Registered Hom mprovement Contractor. .
Company Name Not Applicable ❑ .
Address Registration Number
,��/ Expiation 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
,-;-^� 0 j . / A ( v c) ./ Not Applicable ❑
Na,fm/e(Registrant): b �p `A
11),4 Ji i; 11/ / ejlt-69"-•.e7A 17 4 a.-.Registration�N r// 7
C'Y 0 (;_Y
Address il L C.)0.2`L' (C tTh 3 -) --zei 0 - ?y- Expiration Date?
Signature Telephone , ! /2;3
Section 5.2 Re ' ered Professional Engineer(s)
Name Area of Responsibility
Adccf ss Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Hams • Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Hams Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor 1
4 (,', / 're." ( -- :---)01(}4-1 DTIc,, Not Applicable ElCompany Name
Person Responsible r Construction € 44 t, Oa-Lc'±qiii-)
Address l7/� q `3 (,-,c)
Signature Telephone `E-'
The Commonwealth of Massachusetts
�:
r Department of Industrial Accidents
1 Congress Street, Suite 100
tBoston, MA 02114-2017
5�•`''4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information - lease Print Legibly
Name (Business/Organization/Individual): y , 6--- � r1 ,,
Address: f\ bi r( � <
City/State/Zip:- =' /24 U e 36,D I � 1 � I ine #: 5 b� .)-72
Are you an employer? Check the appropriate box:
Type of project (required):
lI am a employer with ' 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
anycapacity. 8. Remodeling
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 mYProPn3'•
e I will 1 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.E1 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. .❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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.
r
Insurance Company Name: E
Policy#or Self-ins. Lic. #: x raki ate. ! "15 .).3
Job Site Address ` ---
g �� 2 City/State/Zip: _�. Oztzy
Attach a copy of a workers' compensation policy declaration page(showing the policy numbe 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.
i'
Signature: sy� ._i
G.��-- Date: `f� �'
23
Phone#: ,51� 3 e). 7 S
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 oute 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 res Icing from the roposed work/demolition to be
conducted at (3113, 4 4- 2 /-
Work Address
Is to be disposed of at the following location: ' i"----- 'I-OK- C.,L")
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
r---K
(c) - I2--3
Signature of Applicant Date
Permit No.
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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 fJ L1 8 7 g e Zg 56. 94-K-
Work Address
Is to be disposed of at the following location: 3 £'?((B
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
A
•
Signature of Applicant Date
Permit No.
ACC b DATE(MMIDO/YYYY)
sa.iR(J CERTIFICATE OF LIABILITY INSURANCE kissano 03/27/23
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 CONAME:
EACI JIMMY HINDMAN
Schlegel&Schlegel Ins Broker P(pHIc°No,Ext): 508-771-8381 FAX
No): 508-771-0663
34 Main Street EMAIL
West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmall.com
INSURER(S)AFFORDING COVERAGE NAIC S
INSURER A:
INSURED INSURER B: TRAVELERS
ILYA LAVRENOV INSURER C:
DBA A GRADE EXTERIOR SOLUTIONS INSURER D:
393 BUCKSKIN PATH
CENTERVILLE,MA 02632 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 EY 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 TYPE OF INSURANCE ADDLBUBN POLICY EFF POLICY EXP LIMITS
LTRINSD WVD POLICY NUMBER JMM/DD/YYYY) (MM/DD/YYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $
MED EXP(Any one person) $
A PERSONAL 8 ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $
POLICY JECT LOC PRODUCTS-COMP/OP AGG $
OTHER $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
_ AUTOS ONLY AUTOS
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 STATUTE ER
B ANY OFFICER/MEMBER EXCLUDED?XECUTIVE YYN N/A 7PJUB6R08057122 09/23/22 09/23/23 E.L.EACH ACCIDENT $ 100,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
ILYA LAVRENOV HAS ELECTED NOT TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY
INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,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
ACCORDANCE WITH THE POLICY PROVISIONS.
TOWN OF YARMOUTH
BUILDING DEPARTMENT •
YARMOUTH MA AUTHOR! D R ES NTATIVE
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Commonwealth of massacisettsillit
Division of Occupational Licensure
Board of Building Regulations and Standards
Cons �H rvisor
CS-107181
y _ fires 05/27/2025
ILYA LAVRE fOV '
13 BIRCH ST E
HYANNIS Mlt°
6/1I 'd.VD
Commissioner
1
�r��t Nis.`
----7--1-3
COMMERCIAL ONLY- BULDING PERMIT
APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed Work: g-6 8 P-f2s 14 w
Scope of Proposed Work: , ,
f\A-irelt,046e
f t x:h s ) / t24--1 I I l I),► I O t.-Th,
14 _z--s fs iii (7,;l ram, J B L1
Date: �'�� /) u//
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.
/
RecelkAcknowledgement:
?c
Applicant's Signature () —/ — .2-3
Date
Rev. March 2022