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HomeMy WebLinkAboutBLDC-23-20 • , t , • •• .0v2YgR BUILDING PERMIT APPLICATION *4-, ••0 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, i, ••i,. _y OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY E' ».Tten«, r. Ton ofMarmouth Building Department P c ( 7 - '."'~"'*� l 1-tFi Route _'Ii • 1'arrncntlh. yGl()2G6-t--!•-t�)`� � .,. Tel: 508-398-2231 ext. 1261 Fax 508-398-0 �N_.~_- _._,._.._._�__ �!� JUN 02 it � (�� Office Use Only Planning Board Information Assessors Department Informatio ,li PerTTTfi 6 - 2 3_ to Plan Type M ,;i I -�r'''ptl-' Permit Fee $ COO Endorsement Date �`� --� �� Deposit Rec'd. $ r!P(7 Date f�IZ Recording Date New $• cz* f cl i Z Plan No. 14 Pro a im sions: �2 Net Due Other � �� ����" Lot Aria(s) Frontage(ft) Lot Coverage Buildin• Permit Number This Section for Office Use On / a Date Issued: Signature: • _v ol.' 'Z . Certificate of Occupancy.. But: • Official Date is � Is not required Section 1 - Site Information 1.1 Property Address: �, yy �� �� 1.2 Zoning In! rmatiort: `��eacc 7/ Zoni g District Proposed Use 1.3 Building Setbacks(ft) ' Front Yard Side Yards Required Provided Rear Yard Re•uired Provided Required Provided f) / C> � 1.4 WaterSupply(M.Q.L c.40.S 54) 1.5 Rood Zone Information: Co ref1s s � j Public Private Zone: ___ BFE: Section 2 - Property Ownership/Authorized Agent I wnerr of 0 t 4.7 5/- 5e1A-ot44-02-Mk e(p ���1,.� 1,���� Mailing Address: n tore T �`` °'JG?L� Tel�ho��e 2.2 Authorized Agent: alaplaerte- Email Address: tp� t i C 0747 r)/1 t 7, 4jc-e-r6(214b4 Madre Address: Si1V4CVACCX/1/11-.e .1 _ : Telephone � rt.� ✓� Fax Section 3 - Construction Services n7ail Address: j 3.1 LlCsns Construct(o Supsrv(sor. n ? ��f� f Not Ap livable /-t— / f�Y. 0 Ja 7/ 1 Ad r /3 f aA 5Ikilvyq_s D�60I License Number d ess/ ! / y �� 5 —z7 5 ����' t- -�� Expiration Date Signatur Telephone Email Address: • 4 . Section 6 - Description of Proposed Work(check all applicable) New Construction ❑ I (for multiple family only) No.of Bedrooms j (tor multiple family only) No.of Bathrooms — Existing Bldg. $ I Repair(s)pc 1 Alterations pr I Addition ❑ I Accessory Bldg. ❑ Type I Demolition IOther Specify: Brief Description of Proposed Work: r • firr- eguni i �' vJ / k' 9ieJve. &?(o/� -Ti kei, I) ezi-- „....„,,,...„- ie-ep 10-t,i2-5 SMit 5/4 k--1 141 IrJl2 -t.-�S �i i 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 ❑ B BUSINESS (� A-4 ❑ A-5 ❑ 1 B ❑ E EDUCATIONAL fl 2A ❑ F FACTORY 2B ❑ ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ I INSTITUTIONAL ❑ 1-1 3A ❑ M MERCHANTILE ❑ ❑ 1-2 ❑ 13 ❑ 3B ❑ R RESIDENTIAL 4 ❑ S STORAGE ❑ R ❑ R-2 ❑ R-3 ❑ 5A ❑ U TILITYDRA 0 s1 ❑ 5-2 Els6 ❑ M MIXED USE SPECIFY: S SPECIAL USE ❑ SPECIFY: ❑ SPECIFY: Complete this.section if existing uil ing ing.rpno rations;additions and/or change In use.I Existing Use Group: 9 -S E)\i f 9 M P/1 ' 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) J 'b 5(li� Total Area All Floors (sf) �"C / (fT _ Total Height(ft) t (i �`/v 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 O R'S AGE OR CONTRACTOR APPLIES FOR BUILDING PERMIT, 1C7 L. , as Owner of the subject property, 4 ehalf, m- ers relative to work authorized bythis buildingto act on I _ permit application. ignature of Owne ✓/+ � Date r . SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION I, /,--,..de,4 io��' t' t' t, , as Owner/Authorized Agent hereby declare tha the state ents and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Sign-• und.-r the •>-'ns a penalties of perjury. 44,4 i� csiin i ►/l f dr 0, _. y40. -' 'n= /Agent . ,5731-25 Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2 Electrical 3 3.Plumbing/Gas VVV'1 V b 4.Mechanical(HVAC) 5.Fire Protection �e 3e6 ,....-... 5.Total=(1+2+3+4+5) 7.Total Square Ft.(lormw setcenes&addibona) 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 ❑ `y 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 )0, _ t�4�!p(� Not Applicable ❑ Na a (Regitr tM;& 1` , iAvxpoclvesliy(e,�/ } �`�7f/ Regis fipqr48,7 Addr�s� wC�ifC t00,6L��QTT"- S�'2_0Y v V�7 Expi t�'°�1 Date L/" Signature Telephone V/2! '1-,3 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 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 Cyr /q /u S Not Applicable ❑ Cowman N et, hJ Person Resp nsibleConst ction5t � fs..,Address �� rrprl �� t • Signature Telephone -.1 /or7 COMMERCIAL ONLY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: S6 g gRi--- 2 6 Clet-boti /3 -ix Scope of Proposed Work: � �f U611 Jai()—s ied &' I2cicITS 00 2, L.04/ 1.4) 4- p4c4,_, o;( g 'Po rc-_.)1 j ?-oci--kiri 5 ri---/-14-rcLije1,4-1 - 45 iqt)('(.)2-di ) 0'6'I;47.1 LP frie-a-)S Ak,o--)Sken,L5-ey -/--&e_to,„-,iej 0.1,e t &91,Antv,, Date: 3--3/- 2.-3 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 y r you cooperation. Re ei ckn App iicant's Signature Date Rev. March 2022 K ` The Commonwealth of Massachusetts re.,..9-1-11-t Department of IndustrialAccidents _ I Congress Street, Suite 100 47 )9 Boston, MA 02114-2017 s•••`>`t 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/Organ'zation/Individual): A - f- .--4/` i 0 J/o -k .3 iril Address: 64 I7 / St- 1 City/State/Zip: f yO jS ALin N(6 l Phone#: 5D3 3L 0 01 75- y Are you an employer? Check t e appropriate box: Type of project (required): op am a employer with employees(full and/or part-time).* 7. New construction 2.11 I am a sole proprietor or partnership and have no employees working for me in S. gZemodeling any capacity.[No workers'comp. insurance required.] — 3:0 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 yP roPm'•e I will 1 0 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12. 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 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 in urance for my employees. Below is the policy and job site information. i r ( J / Insurance Company Name: S//l- Le-9 f CJ l Policy# or Self-ins. Lic. #: ` �p - ��� � �-- ogo r/Liration Date: 9/2-3/2-3 Job Site Address: �ID ("1- 7g Q4-2,, City/State/Zip: 41 6 2- /Attach a copy of the workers' compensation polic ` ecla yq--,-- on 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. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 5-- 3, ,z /-� _ . phone#: 5-0 g 3 (e 0 2-7 5 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#: 11 1 it tor a.) . `* ' -C) --- —------- --- ----.....--- ---,..—.............--------- 1 _ . ar,ri c -so is Irrar4 II .10 $- 0 C a3 corv;scri.P) 7'- n 4-, , , f 1 .=. ::,. — 0 0 ,..-t cz 0 Ld "0 0 4-"' L'.1 C ri) '0 ° , 2 L— ,,, f2 co ,„ te .4. . ..1 0- 73 >3 0 U) Ca '` .:7R., (1.) V". VD f NR4V c4:6% 4'MT C,.. thai 7, . 1 1 .... 4....4.,.... .. . , . „ . ..„.....„.„=c 1...c...cc „....„ i 54 yr_ 4P. _ . NT,L.'eV 41 I NI i 1,&"101 I i. 4 .SNMOSVOI)1C4). 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CV Z ;7-7 'CO ).• 00 tol • 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 J conducted at ( L/` g 7 g jE� 2s Work Address Is to be disposed of at the following location: £ CD Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. NL d 17/// / (;-3 Signature of Applicant Date Permit No. C DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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 CONTACT NAME: JIMMY HINDMAN Schlegel&Schlegel Ins Broker WCNNo,Ext): 508-771-8381 FAX (A/c,No): 508-771-0663 34 Main Street ADDRESS: schlegellnsurance©gmall.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# 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 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 AUULBUHR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JEt'OT 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 Y/N STATUTE ER ANY B OFFICER/MEMBER ER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE Y N/AE.L.EACH ACCIDENT $ 100,000 7PJUB6R08057122 09/23/22 09/23/23 (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 TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 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 Massachusetts Division of Occupational Licensure VI Board of Building Regulations and Standards Cost Efieon visor CS-107181 - `� ILYA LAVREOOV 7,1 res: 05/27/2025 13 BIRCH STREET HYANNIS Mom' • t' Commissioner