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HomeMy WebLinkAboutBLDC-23-18 r • of•Yq,4 BUILDING PERMIT APPLICATION ' . • dr, APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, 0 , C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAp4FrWEwwG t'a ••• Town of Yarmouth Building ,��va e s "kTTACMCCf Department 6a ! Ud' �"-.n•*,,Ca' 1 146 Route _S • Yarmouth, MA 0266. 4492 1, f ,1„it Tel: 508-398-2231 eat. 1261 Fax 508-398-08 6 JUN 02 2023 Office Use Only Planning Board Information Assessors Department Informtti Perri t4d..G-- -3 r?ate Plan Type Map 1'v _Lot al r'aR I roi N i 4 Permit Fee $V9iJ Endorsement Date %'.1-Z-Si / Gf I Recording Date 461 New Deposit Rec.d. $ b0.0 Date h2it. Plan No. 1.4 Property Dimensions: Net Due $ )1 IG 12 Other 1l k' ',Oci.2.-- L. / 0 ' 7 ? J_, Lot Area(sf) Frontage(tt) Lot Coverage This Section for Office Use Only I E L) Building Permit Number: I Date Issued: ' Signature: �' �� ✓� Certificate of OcupnciUN 0 2 2023 Building Official Data is/-. Is not ,� _ _..required Section 1 - Site Information I 61/ .. I By ,.._. ------- i.t Property Address: �w " i n �� nd_s J 1.2 Zonin Information: 65c S }�. (�—'" .-4°- 63 Ilit._3 r',. --)i-kfr4.1.5 . p L.rS -v\i— via- -6' Zoning District p -FepoSd Use 1.3 Building Setbacks(ft) ' el 1 ` -p-i-- Front Yard Side Yards Required Rear Yard Provided Required Provided Required Provided 1.4 Water e _.-- w << j Supply( M.n.L c.40.S 54) 1.5 Flood Zone information, ; . ; t, - Public Private �: — BFE '' Section 2- Property Ownership/Authorized Agent s" MAY 25 20231-jN1 : . 2.1 Owner of Record; /�y I"! ,L1?INC f ,. I. � , .ate t:� () 'ti.ri' / 7 Mailing Address: 0(F..—Ei.3)v irwii {,...T.,67z__ Signature Telephone 2.2 Authorized Agent I Email Address: N I t� 67 -L 1�- { ,RelAotiA 0 ' Mailing Address: / Signature Telephone '4� 10-4( OUV1.17ye)46Z-r C'_Crx"L arc Entail Address: I Section 3 - Construction Services 3.1 Llce sed Const ctlon Supsryiso . ��`` Not Applicable ID A 4t uv ic r (3fr-A9— ✓1 ) �/r { Lic Number'sC)Address , 1 (, / ` 1 Cam' / r tS,' _. 46,,,zdie-(.7,kr,,,,,, s-D ExpirationDateSignature Telephone � Erna' Address: )._ '] , ., SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION ! 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 of perjury. ` ...24/ ...6,4,49- Print ame ' atth(�of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS IJgm °l ,/�� Estimated Cost(Dollars)to be C• .(-�, �'V 0 on completed by permit applicant 1.Building 4,..„?........_t 2 Electrical#. 3.Plumbing/Gas -e 4.Mechanical(HVAC) S.Fire Protection /‘.`' fi.Total=(1+2+3+4+5) $33oL / Uii.J - 7.Total Square Ft.parnew smem,es 6 addibo,el �7 �/ t. Check Below ' ' ❑ Conservation-Commission Filing C5° (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) 3 Registered Home Improvement Contractor. ompany Hama Not Applicable ❑ r Address Registration Number Expiration Date Signature Telephone \4,�, 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 den'al of the issuance of the building permit. Signed Affidavit Attached Yes . . No Secti 5- Professional Design and Construction Services-for Buildings and Structures Subject to onstruction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) i Section 5.1 Registered Architect Not Applicable ❑ Name (Registrant): L (lc/ Regist ion Address/� / '� ���) M I (ev, 1 �, rc.� 1 - / 1( l�}07(/ Expiratron Date -,Signature A ,if,)raf A Telephone tJ (/ /..)/)g Sectiofi 5.2 Registered Professional Engineer(s) et`1C-1' v'/{4y Itt-b ' ,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 Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3.Gener�all Contractor� 4—C:41 lit^ J (.11 -y- JL) e,)/(1 11 ,,S Not Applicable ❑ Company Ns_jr, ,, A LAp 1A"lr ie-el")t b Perso Re onsible t r st ction MO I Addr sj r �i "}r7 Signature Telephone , • j I ' ; , Section 6 - Description of Proposed Work(check all applicable)1 New Construction ❑ I (for multiple family only) No.of Bedrooms 1 (for multiple family only) No.of Bathrooms . Existing Bldg. a Repair(s) 4 I Alterations Ch I Addition ❑ I Accessory Bldg. ❑ Type I Demolition Other Specify: 1 . Brief Description of Proposed Work: • PbvcjA K r7)aa-b 17 ({i` { /1 d c'i/ 13 Y/ i" �Jilo Acti, I. U-i--1 ) 't--() v-r•-i'v\<10/0 c4 4)--cJ 44-ki N-11 3-t)2_3_ 4;0 a,A.t,4-1,0 f,,,,AL,./111-00( C. Section 7- Use Group and Construction Type I Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 0 A-2 ❑ A-3 ❑ to ❑ B BUSINESS Ii 7.3 A-4 ❑ A-5 ❑ 113 ❑ E EDUCATIONAL ❑ � ❑ F FACTORY 2B 0 ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ i-i ❑ 1-2 ❑ 1.3 0 38 M MERCHANTILE IDID 4 ❑ R RESIDENTIAL S STORAGE ElS-1 ❑ S-2 ❑ R-3 ❑ SA Ea ❑ SB ❑ U UTILITY CI SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this section if existing building undergoing.renovations;additions and/or change ih use.1 Existing Use Group: c-J a---- Ye- f ..Q_ �f `�V{ Proposed Use Group: 4' Existing Hazard Index 780 CMR 34 Proposed Hazard Index 7B0 CMR 34 Section 8 Building Height and Area Building Area Existing(if applicable) Number of floors or stories / Proposed include basement levels / Floor Area per Floor(sf) l'5e) 5 Total Area All Floors (sf) 54 /r- \ _ Total Height �� � 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 QRCONTRACTOR APPLIES FOR BUILDING PERMIT 1, Of ra_va vi 6/ t , as Owner of the subject property, hereby authorize . i_\ Li1i 0(J my `ehalf, in Tatters relative to work authorized bythis buildingto act on I permit application. , t c -1.4pt' ,,,,;„...._ Signature of Owner ").- Date 2,--/ -AY- ;LI / COMMERCIAL ONLY— BOLDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: r>V���/ U C p 5,, Scope of Proposed Work: 7117',C. 1 P tfa;{/0'1 j ) �5 A ( -tit" r; Date: 7~)i/ �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 you for your cooperation. Receip -f r owl gement: Applicant's Signature Date Rev. March 2022 The Commonwealth of Massachusetts r Department of Industrial Accidents 1 Congress Street, Suite 100 t Boston, MA 02114 2017 �:5 wwN.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le ibl Name (Business/Organization/Individual): lj / • • Address: 1 rat City/State/Zip: 11 MO A D Z D I pp Phone #: 5bb 3(0 , 75 Are you an employer? Check the appropriate box: 1. I am a employer with_�_ Type of project(required): employees(full and/or part-time).* 2. 7. I am a sole proprietor or partnership and have no employees working for me in _ New construction 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 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 CI Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.El Electrical repairs or additions 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.Ell Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.; 13.0 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 nzy employees. Below is the policy and job site information. Insurance Company Name: i.'" ,S C/A I...(14 Policy#or Self-ins. Lic. #: �PSUjK©g 57 �� Q Expiration Date: Z3 2-5C� Job Site Addresg 7 C� e+ 1 g City/Ste/Zip: 6Attach a copy of the workers' compensation policy declaration page(showing the pol policy num rand expiration� 7 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: Date: - • - Phone#: 8 L% 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 �J(C"/ 8 7 g et 4 'zj. froiY Work Address Is to be disposed of at the following location: 5 T&?Q::1Th Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. //', 7-* 7f d S Wit, , .23 Signature of Applicant Date Permit No. i 1 • AR'? CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 5 34 Main Street E41A No,Extt: 08-771 8381 Fa No): 508-771-0663 West Yarmouth,MA 02673 ADDRESS: Schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC C 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 AUULSUNK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD, POLICY NUMBER (MM/OD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE 10 Rtel 1ED 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 JECOT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY AUTOS ONLY AUTOS (Per accident) $ 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 PROPRIETOR/PARTNER/EXECUTIVE 7PJUB6R08057122 09/23/22 09/23/23 E.L.EACH ACCIDENT B OFFICER/MEMBER EXCLUDED? Y N/AS 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!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! Dlsl< • NTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • .111/1 Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Const( S 4 rvisor CS-107181 ~' fliplres 05/27/2025 ILYA LAVRE(j[OV 13 BIRCH STREET • 11111 • 1.„ HYANNIS MAp21" 4'f)IJt'd.10' Commissioner • • • • -1. _ ....__ • (4.) niibt")9 f ''- I c, f ` i I'2'1 > CO ..0 a 444 OnwsinumeiNiumialll41.1004, 44, 0 til = (1) 4,4 i'l i NO 4(crk Cs,1 cnati a) ttN, t-, -0 p f v.: 0 , ti CZ 7D Z r% 0 0 a -- -0 .,,. a) S...)' — 4.0 _ .-....1 0- . .. .- (Z, ..-.7. CGO\•,..);& .........- ,,,,'. . / — r_,")N.....................w. , Iscj 07,. - , ,.. .....7- ----.., --, too- t i - --, 1 4. .1 , .7. NO' 44. , ... ..- . ' Qr2741 p ti , 4 <.N., s> _...,... 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