HomeMy WebLinkAboutBLD-22-007417 ' j
_.oF:Y,liR BUILDING PERMIT APPLICATION
. 4r APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE,OCCUPANCY OF,
",1 ' C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMIL u ELUNr;
O .. Town of Yarmouth Building Department RECEIVED
t' 'TT:�0.;' *2.
1 14fi Route 28 • Wrrnouth, MA 02664-4492
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 JUN 22 2022
Office Use Only �`� Planning Board Information Assessors Department Informatio
3 U I L rX�¢ra
Permit No.CIU"��-"� Date Plan Type Map �;Yr.�t�/-YV---_ __�----_____._.
Permit Fee $ 6O.u Endorsement Date /
Recording Date New
Deposit Rec'd. $ (to Y�Date Plan No. 1.4 Property Dimensions:
Net Due $ Other Lot Area(st) Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number: Date Issued
Signature: / C- 3o - )� • Certificate of Occupancy
u g Official Data is Is not required
Section 1 - Site Information
1.1 Property Address: 1.2 Zoning Information:
244, P'lktot r (ice 4,4 *R-4D A- -3 .t-f
Zoning District Proposed Use
1.3 Building Setbacks(ft) '
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
3D 5 2.4, 2-e) 14.0
1.4 Water Supply(PA.Q.L c.40.S 54) 1.5 Flood Zone Information: Comments '
ublic_) Private Zone: BFE '
Section 2- Property Ownership/Authorized Agent
21 Owner of Record
Tiv,1/4{4.rievtvitt Pew atatztt Pres. (evh'on Po 8.( 2 3 -- Y Apt,t—
Name(print) 7.� 'y
nt) Mailing Address: 0
rY�'� --.1"---"' IV II-515 5qL$ ofs 14-Ic-{' -7 368 every0
54)
Signatur Telephone Telephone
Email Address: I
2.2 Authorized Agent 1.141rrr il pti'C6nylw,
o via_>t-,4-Mo r- ri I - iror- tcs I -d +
Name(print) Mailing Address:\Jair1,N„GiA-C Pao I-(+ - Oj2,4'
l0 t G1 q- 51.1 15 i/,4" hut.6 Ise st'i•1-‘0 L . 4414 ,
Signatur Telephone Fax
mail Address: I
Section 3 - Construction Services
3.1 Licensed Construction Supervisor: Not Applicablejg:
License Number
Address
• Expiration Date
Signature Telephone Email Address:
•
' , Section 6 - Description of Proposed Work(check all applicable)I
New Construction ❑ I (for multiple family only) No.of Bedrooms I (for multiple family P only) No.of Bathrooms
Existing Bldg. pi I Repair(s) I Alterations ❑ I Addition ❑ I
Accessory Bldg. 0 Type I Demolition Other Specify:
P fy:
Brief Description of Proposed Work:
Repittac -Prc.:S4,t 1 44 I►ti/tat v,t,, d,( , -4D kef- .
Section 7- Use Group and Construction Type 1
Building Use Group(Check as applicapable) Construction Type
A ASSEMBLY
.A-1 ❑ A-2 ❑ A-3 A 1A ❑
B BUSINESS ❑
A-4 ❑ A-5 ❑ 1 B El
2A ❑
E EDUCATIONAL ❑
F FACTORY 2B ID
❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD ❑
I INSTITUTIONAL ❑ I t 3A ❑
M MERCHANTILE ❑ ❑ 1-2 ❑ 1-3 ❑ 38 ❑ _
R RESIDENTIAL 4 ❑
S STORAGE ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
u UTILITY0 s 1 El3-2 ❑ se El
SPECIFY:
M MIXED USE ❑ •
SPECIFY:
S SPECIAL USE ❑
SPECIFY:
I
Complete this.section if existing building undergoing.renovations;additions and/or change in use.I
Existing Use Group:
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(sf)
Total Area All Floors (sf)
Total Height (ft)
Section 9 - STRUCTURAL PEER REVIEW (7B0CMR 110 11) I
Independent Structural Engineering Structural Peer Review Required Yes No 1,1.ti.�J
.. I
SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, y4,044471-4 Neu, G tmk,14 tiro . F1.4.44,4`Jv\__..
n , as Owner of the subject property,
hereby authorize NRl- rt 44.4
my behalf, in all matters relative to work authorized bythis buildingto act on
permit application.
Signature of Owner
Date
SECTION 1 Obtt 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.
Print Name Awe, 4A/ 46/f-dP 5/1 kVA-.
•
7 ! L
Signature of Owner/Ag n �`
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)
7.Total Square Ft.(iornerr s trues&addition)
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
•
•
•
•
•
3.2 Registered Home Improvement Contractor:1
Company Name -
Not Applicable ❑ -
Address Registration Number
ISignature Telephone Expiration 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 denial of the issuance of the building permit.
Signed Affidavit Attached Yes No .1X,....
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
+ - Ali W Attr% �i5l I4, - Not Applicable ❑
R
Hams ( is rant): # J'rant): 411.1i 5 twit Ma, I Regist Lion Numbe
Addre s 1 # ��
t b O I(Al"t:1 Expiratio Date �1
Signature Telephone 8/ / t Vl
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
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 General Contractor
Not Applicable ❑
Company Hame
Person Responsible for Construction
Address
Signature Telephone
The Commonwealth of Massachusetts
- Department of Industrial Accidents
�:: t 1 Congress Street, Suite 100
'.°r.; T Boston, MA021142017
n
.:5�,''. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
Name (Business/Organization/Individual): Ilif:tliA4i 4-x. . (11,L, h ( MZ�511
Address: W444 9}- 2 �1,{� �..4 s5 L - C J I
I
City/State/Zip: A4i M WA- i2o I Phone #: `G .-qo neepr''
Are you an employer? Check the appropriate box:
Type of project (required):
—
1.7 I am a employer with employees(full and/or part-time).*
7. _ New construction
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers'comp. insurance required.] 8. 7 Remodeling
3.7 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 roe I will 10 — Building addition
pensure 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 12.7 Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.1 13. Roof repairs
6X We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 1, ��E
152, §1(4),and we have no employees. [No workers'comp. insurance required.] / 'Lkkitdr
*Any applicant that checks box 41 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:
Policy# or Self-ins. Lic. #:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Pljt)
Pho � �m Date: JvA - Z �(� i
ne#: b T"(N , *tor
r
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::YA►RMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-22311 ,ext. 1261 Fax 508-398-0836
Office of the. Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS.DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 6
Work Address
Is to be disposed of oat the following location: -r x. `�' /a vk/ w ,
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
Signature of A lication Date
Permit No.
I ,
•
•
•
--
(40 COMM•NWE'LTH ®F
DIVISION OF PROFESSIONAL LICENSURE
•
BOARD OF
ARCHITECTS
ISSUES THE FOLLOWING LICENSE cc'
REGISTERED ARCHITECT,
MARY-ANN AGRESTI
68 CENTER STREET
s
UNIT 22
HYANNIS,MA 02601-5575 '
•031,1;0 : 106093
LICENSE NUFABEN tXPiHAi iUN UHft sENiAL NUMBER
r..
•
•
•
•
E_
Y^h TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
ti C — Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
J+�rl `), t )r _
' 4 KING S HIGHWAY HISTORIC DISTRICT COMMITTEE
•
APPLICATION FOR
ai_t)K1NG°S HtGhw,ek
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly: ttt r Z.
Address of proposed work _ ``( ((P N'L St. Map/Lot# /27, ! /' p
Owners) (✓ l2 t /4 t 1 atidi ! /pr.Phone#: Lj 1
All applica ions must be submitted by owner or accompanied by letter from owner approving submittal
�ofrapplication.
Mailing address:,_ aq 3 L` `Y4` 4 Year built: /p 7 w`
Preferred notification method I/ Phone Email
Email, ��t, � • �' /�i!5�7 � G _
Agent/Contractor. Phone#
Mailing Address 1 I (f11� �%1 /�� s / Irl j YL L:!1 ..-._ .(+u`i
Email i Preferred notification method, Le Phone Email
Description of Proposed Work )
/ (Additional pages may be attached if necessary �r 1�
�/a I A;fcg 74,ibe�i4 /.t f� ,t!t y..G it Xiet c'�G tAte J,
iary; . � Aiatic) lz
Signed(Owner or agent). Date: Ze '2_
v ownerlcorstractorlagent is aware that a permit may be required from the Building Department.(Check other departments,also.)
This certificate is good for one year from approval date or upon date of expiration of Budding Permit whichever date shall he later
for Committee use only:
Date .._i 1J 1/.f_ Approved Approved with chap.-. 1. fi�Tl
Amount_.. V_._Gt) Reason for denial:
CashiCK it; c9557.�
YARMOUTH
Rcvd by: +1 0 I HWAY
Date Signed 0212401 �,'p
_.....-. signed: /� eitEeNt`� eirn�( � APPLICATION a
V5 n17
TOWN OF YARMOUTH
1146 ROUTE 28,SOUTH YARMOUTH,IVIASSACHUSEITS 02664-4431
Telephone(508)398-2231 Ext.1292 Fax(508)39841836
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
WAIVER OF 45-DAY DETERMINATION
The applicant/applicant's agent understands and agrees that due to the current declared National
and State public health emergencies the determination of our Application for a Certificate of
Appropriateness/Demolition/Exemption may not be made within 45 days of the tiling of such
application.
The applicant agrees to extend the time frame within which a determination is to be made as
required by the Old King's Highway Regional Historic District Act,
SECTION 9-Meetings, Hearings, Time for Making Determinations
"As soon as convenient after such public hearing; but in any event within forty-five (45) days
after the filing of application, or within suchfurther time as the applicant shall allow in writing,
the Committee shall make a determination on the application. "
Applicant understands that the review of this application will be scheduled as soon as the
situation allows.
Applicant/Agent Name(please print): utk,
Applicant/Agent signature: t\kkat 11/41.1 iJAgs Date: VP,
jitt: 4 -
)4,
,t)
0LO 4411
JUN 2 7 2022
YARMOUTH
K'tANIE:S%'-'0G1 .51—
LD KIN HI HWAY
Application ..082-
312020
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V." 04
Sherman, Lisa
From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net>
Sent: Monday,June 27,2022 5:25 PM
To: Sherman, Lisa
Subject: Re: 22-E082 266 Route 6A
Attention!:This email originates outside of the organization, Do not open attachments or dick links unless you are
sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure.
Otherwise delete this email.
approve.
Richard
On 06/27/2022 10:23 AM Sherman, Lisa<Isherman@yarmouth.ma.us>wrote:
Hi Richard,
The Yarmouth New Church Preservation Foundation wants to replace the rotted
ramp in the rear of the building at 266 Route GA.
Please let me know if you need any additional information.
Thanks Richard,
a It
Lisa
JUN 2 7 2022
Y
L OLD,,,,ATVI-tr-iiiGZIAY I
Lisa Sherman
Office Administrator
Old Kings Highway Committee/Yarmouth Historical Commission
Town of Yarmouth