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HomeMy WebLinkAboutBLDC-23-19 r • • of•-'q,4 BUILDING PERMIT APPLICATION • . ,. '$O APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE ''UPANCY OF,_C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMIL r�Y LI .c •a r - AD- Town of Yarmouth Building Department `- M4TTaCM[�y `"^-a,•'* # 1146 Route 28 • Yarmouth, 1G1()`�664-•1•- 92 i ! ~ Tel: 508 Li -398-2231 ext. 1261 Fax 508-398-08 6 '�' 2 2023 Office Use Only 1-)\\‘-'s).\'./‘ ‘. §/ Planning Board Information Assessors Department Informatm .p ��I Di NC [at-NgRIME �_ Date Plan Type nfa . .M Permit Fee $ (Cr© Endorsement Date (r' U / / Recording Date New Deposit Rec'd. $ COO tif0 Date 69e • cot K'i )2... Plan No. �.u �erty r',�C sio C� 5- r1 Net Due $ 5—�Gi Other ✓ / l� r Lot Ar - (sf Frontage(ft) Lot Coverage Building Permit Number This Section for Office Use Only Date Issued: Signature: -+ fj`et)f� Certificate of Occupancy `$uilding Official Date is. _Is not required • Section 1 - Site Information 1 1• Prop: AddrP29 s: /�!(-(- 6 > 9,411(4n i- , r 1.2 Zonin#(s.4 g nformation: tic .-e,, .4z ..) , l� ___ ________ . Zo ing District Pir000sed Ike 1.3 Building Setbacks(ft) . ��— Front Yard Side Yards Required Provided- Rear Yard Required Provided Required Provided ..• 0 I q°41 ID .)-,5-1 -3 D ' e -17— 1.4 YQater hr MALL-c.40.S 54) 1.5 Flood Zone Information: V� OC1: C• ommentx Public Private Zone: BFE: • Section 2 - Property Ownership/Authorized Agent I Owner of Re o , „,/, 6764k (print) -er-- fradVf Mailing Address: ) 4t nature Tel 3 fzfirlt2L.,E670/eitt ep-1, Veil`ephone e _ Veil ,� 2.2 Authorized Agent I Email Address: / 0 i6,71m17-1,-) i 47,60.,,,4Q---6460-4--0-4(yY • (P ) � Maili g ddress: 6/76 . .� � , ig fe vL C7J�� 1( 7Y� ��C> , f� Telephone Section 3 - Construction Services i:ntiail Address: 3.1 Licensed Construction Supervisor. Not Applicable ,,iP f,�CI\ St" 4/4/11 (S C7 C/ License Number \F,..i Addr ` cJ`7� Expiration Date Sig tyt a �� Telephone Email Address: t Section 6 - Description of Proposed Work(check all applicable) • New Construction ❑ (for multiple family only) No.of Bedrooms (for multiple family only) Existing Bldg. I Repair(s) No.of Bathrooms _______ ' �' Alterations al Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: Brief D-scription of Propose. Work{- b ' +(il 0 �6YUy1 R-ft t. . ' <12r e. ti Eigs 0 heraMISMEareflAPPAA 11 . i t II Meer ‘,t _ 4 ,, r , It _ , toioef-- ifi 0 „ dm, frer-e-41. a ,5 cfzi-ler ,e=e) AC LOS • _IV Sat tnnf ' i,;4 ` Section 7- Use Group and Construction Type Building Use Group (Check as applicapable) I • A ASSEMBLY Construction Type ❑ 11a 1 A-2 ❑ A-3 ❑ IA ❑ E EDUCATIONAL ❑ ZA ❑ F FACTORY ❑ F- ❑ H HIGH HAZARD ❑ t ❑ F 2 ❑ 2C La I INSTITUTIONAL ❑ 3A ❑ M MERCHANTILE ❑ I-1 ❑ 12 ❑ 1-3 ❑ 3B ❑ R RESIDENTIAL ❑ 4 ❑ R-1 ❑ R-2 0 R-3 ❑ SA ❑ 5 STORAGE ❑ �EllgaMiln ❑ , 0 S-2 ❑ SB 0 M MIXED USE ❑ CEE=111 ❑ Complete this.section if exit ing building undergoing.renovations;additions and/or chap Existing Use Group: ge Iri use. Proposed Use Group: • Existing Hazard Index 780 CMA 34 Section 8 Building Height and Area Proposed Hazard Index 780 CMR 34_.______ Building Area Number of floors or stories Existing(if applicable) include basement levels Proposed Floor Area per Floor(sf) Total Area All Floors (sf) IINP;V_ ";i �AIMIIIIIIIIIIIIIIII Total Height(ft) --Iwo �� it Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes.......... SE, ON 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN No 0 ,; R' , AGEN ,,,j,; C. TRACTOR APPLIES FOR BUILDING PERMIT Of , as Owner of the subject property, JbY author' 4 f `fehalf, 'n . ►_ rrs relative to work authorized by this buildingto act on la 'Ad. ,AL 1, / Permit application. Signature •t Owner zy,�? Date • SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION I • 1. j L /elm/1 / as Owner/Authorized Agent hereby declare that he 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. 1PE 4 At( /* ig re of O, er/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2_Electrical 3.Plumbing/Gas �"7 IIQ) 4.Mechanical(HVAC) • S.Fire Protection 6.Total=(1+2+3+4+5) () a( • 7.Total Square FL pornsw smrmnes&adddioes/ (7.1 v Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) 3.2 Registered Home Improvement Contractor.I Company Name , Not Applicable CIAddress Registration Number ISignature Telephone Eli anon 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 nJ'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: ;ail Not Applicable c-.)Na40cf.A.A.k.../ a (Registrant): / Address C `'t J "�-i'/41 S f*lr .''��Registrati n N b� 5(i Signature Expiration D e Telephone l.3/ z Section 5.2 Registered Professional Engineer(s)I 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 P Expiration Date Section 5.3 General Contractor 4 er _o(Q--- C yr/ y- 1;,)/-16—?, Not A licable Company NamePP ❑ Person Re onsi a J---- Con ctio A- LAV-eW • .� -\ 62 01 Addres ` f Y--- Signature 31 C2 757'' Telephone 4 COMMERCIAL ONLY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE of Address of Proposed Work: � g•7 3 f r Scope of Proposed Work: i (L^<fr Veit)j'Id, , ill/L&L) Sti 6/.0.)24/Ai,,(Qtpi,r4-c,c. P cruk., do.borlduzip 16 oite ou,)- 2, PAM Or por/i.,' ./. c..)7--1-i-v , 'O. //) Date: '-Z Z,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 c peration. Receip nq /..,<",s, ,e 5,--17-3 Applicant's Signature f Date Rev. March 2022 The Commonwealth of Massachusetts Department of Industrial Accidents his 1 Congress Street, Suite 100 "ii 1I'— Boston‘71, , MA 02114-2017 ii, t ••5"' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A Iicant Information Please Print Le ibl Name (Business/Organization/Individual): (.j 1 • Address: r a/ r ' , 9- - City/State/Zip: aL Ai 4 .......,.,.. Phone #: o33U) g.75 Are you an employer? Che k the appropriate box: I. Type of project (required): . I am a employer with _employees(full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in 7. ❑New construction any capacity.[No workers'comp. insurance required.] 8. Remodeling 3.0 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 p 1 l.[] Electrical repairs or additions proprietors with no employees. 12. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Plumbing repairs or additions Roof repairs These sub-contractors have employees and have workers',comp. insurance.: 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'compen -on insurance for nzy employees. Below is the policy and job site information. Insurance Company Name: i /? t7 Policy#or Self-ins. Lic. #: 1 ' Y 12._ / expiration Date: q ,23 ..,2 5 Job Site Address: Attach a copy of the workers' compensation polic eclaration page(showing thetptpolicy number and tion z(c) 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 coverage verification. g of the DIA for insurance I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Phone#: IP Date: _5 / • Official use only. Do not write in this area, to be completed by city or town o i . ff ccaL City or Town: Issuing Authority(circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical 6. Other Inspector 5. Plumbing Inspector Contact Person: ` Phone#• Icy-a a) - a ru co (4‘441-15. errAti 141. r---'" t--- (4- 'NI of\ crar-i 'f 1-174 4.:4 0 I - t „I -0 R cv) zi 'kj L.... 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Cm 44, CO 2 cv • **", u es4 r••• • t..) 0. fa 4! 1E to eV il 13 0 § 'w C 'c -8 ' ' :092 -8 : 2 ts- I 3 li-. .° ,g: . co v, Q. cv z ,-. .z,-, - § -r.-, 3.1 -8 §" t-4 'e-Yi 2 TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA, 02664 508-398-223.1 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..— $ 7 g et Zi. jpiy- 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. .1c ' -/ 7// z/r/ ig Signature of Applicant Date Permit No. AC R' CERTIFICATE OF LIABILITY INSURANCE °ATE'MMID°"'�"' 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 CONiAGt NAME: JIMMY HINDMAN Schlegel&Schlegel Ins Broker PHONE ExU: SOB-771 8381 FAX 34 Main Street AIL (A/C,No): 508-771-0663 West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: INSURED INSURER B: TRAVELERS ILYA LAVRENOV INSURER C: DBA A GRADE EXTERIOR SOLUTIONS 393 BUCKSKIN PATH INSURER D 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 AUULBUNK 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 $ CLAIMS-MADE X OCCUR DAMAGE 10 RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY( I JECT I I LOC PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY(Per person) $ OWNED ^SCHEDULED _ AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER OTH- ANY PROPRIETORJPARTNER/EXECUTIVE Y/N STATUTE I ER B OFFICER/MEMBER EXCLUDED? Y N/A 7PJUB6R08057122 El.EACH ACCIDENT $ 10Q 000 (Mandatory in NH) 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 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! D R ES NTATIVE _ I ©1988-2015 ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved. III Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards ConSt&j rS -re" CS-107181 v • ILYA fires O5/27/2025 z p LAVRE y 13 BIRCH STREET HYANNIS Mle') '' t i'�rrf�aa'aao� Commissioner