HomeMy WebLinkAboutBSHD-23-105-applicationAPPU
BUILDTNG PERMTT APPLICATION
CATION TO CONSTRUC BEPAIR. REA'OVATE . CHANGE THE USE. OCIjUPAN CY Oqt.OR DEMOLISH AI'I/ B OTHEH THAN A ONE OH TWO FAMILY DWELLING.UILDING
Torvu of Ylmmurh Brrilrling DeprnnrcrrtI l.{6 Rourc !B l:lnnouth, ltL\ 0?(i6+t{t}2rel: S0&J9&22JI e* 126l Fax 50&J9&0t36
r,3 Fho.i aonr hlorrratiotr:C@trrncntt
Zone BFE
al Oxn.r gl llcar*
Nt (P'tn0
gnaiJrr
o
,il
MEUlng AddrEes:
442 o
S
Telelhonq
MalliE Addre6!:
EmailAddress:
Enail Address:
IBlephonc Far
c+ ob o4
Sec1lon 2-Pt ed
Permil Fee S
oeposit Roc'd. t
Net Due S
offh! Usr onty
Date
frmhg foard hlormdi;
Plrn Tvor
Endofirhint &1,
-_
fllcording Oalr -...-.
Plnn lto.
0thlr _-...-
lsslssoB 0lpafirud lnlona.tilr
w
LolCovlhg!
-Emrt-|mffig! (tl]
l.{ Pro0lrty oh$shn$
Thb Secdcn for Offea
Date
Dal!Officiii
Cartincah of Ocspanc,
It
1Section ISite
r,2 Zonlng
Zoning D UIL
202
Bv:-
Side Yard8 Rsar Yard
t. t hrop.rt, ldd}.r.l
-3 3.tb.ctr
Front Ysrd
P Provided Provided
Public Priraiu
t.. tlLt.,sl9Dr, (ll.o-r-a- aO. t tal
\1 construction Servlcgs
uot &Cbauo D
ail Address:
o LAddre
9
3,1 Llc.nr.d Conrltuctlon 3urrrrl.on
nf2.2 Authorizod
|ill rcr4
Explrr0or OlEb-Eo-h
Permit No. ,", _ oato _
Slgnatrre:
11
t BdldlnE (ft1
Socdon
Lic€nsa Nun|bor
S€ctlon6-ofP Work (cir6ci .ll appncable)
rzATl0ECTSoN0aowNREAUTHOTJ N TO BE CO FLFTEM wDHENIYow5ERAGRoRAPPLIEsBUFOBILDINGPEHMIT
Section I STRUCTU RAL PEER HEV EW BO7 MHc 110 1
rBd Ysg -
lndspondont Structural Slruciural prrr Rsiow
oSectln I Buirdi Hei ht ard Area
ArE a ProposrdNu{tff d lloors or lbdesirElld!bagemer
Floor Arla D€r RE I!r)
Total AlrArBa tsFloo s0
Total
bu.lldi
lri usB.undstBthsectionitexisti t€novationq,additions ancl/or
780 CMn 31&ishg Hrad lndex
Exlilhg UB. Gmirp:
Fropcld u$ OrorB
Proposed Hgzari lrdBx 780 CtttFl g4
oNew Construcuon llDr ilgh Irmtly only)ot EadmorGExlslin08rd9. O {lor rlph lrmlly lv)ol Bathroo msRrprk(5J o AltrrEtlons QAccessory eldg.Typa <\)bi-o Demolition Othor Specify:
\OAV
Brief fk:D nEscriptio Proposed o
Section UsE t>and
GUseBuildrngrosp applicapabl6 Construc,tion TypeA ASSSUALY
A-la tr r.l Q ^,3 B
E EUSINE.SS
IAE
IBQ
E EDIJCATIONAL
F FACTORY
F.1o F.2H HIGHHAZAFD
2^n
26n
2co
rNsTnmor{ tI
t1 l3trF?u MERCfAfft.!
30
360aF RESTOBINAL traR-1 8-?&3S SIORACE 91U UlllJrY
5afl
58 l'ltrU MIXEO USE os scecret usi o EClFli
SPECIF.|':
!PECIFY
my beha[, In all m6tt8nr Uve to work
, as Ownar ot tho subigct propgty,
Srgnaruro Ol O,rnsa
<.
authorhed by this building p€rmit applieation.
Dati
to act on
'1
I,
herEby authodze
No ,....--.
No.
o.
Addltloo Q
of
(Chock
Y
X
+
1@o D N
Pdnt lErl9
,,
V
Date
w-b-z?ol
hereby forgo
Signed
, as Owner/Authorized Aggntthal fi8 statemgrlls and lnlormation on the ing application ara Irua and acurete. tEthe besr of rny knowl€dg. and belial,
undet the pains End pena €s ol periury,
MATED'lSEctrbn,ESTI COSTS
Esl&lirr!{, gorl (DolE s) 10 br
caEplrt* by pfinf 6pp,crrt
Z Erclricrl
4. ua(*ldcat {HVAC)
5. Fh trq.qdon
aTcalrn+e+!+t+s)
Total7 Sq,l.rr ,
E Conscnaton€omhbdonFlllng
(il app cabte)
A Old tonEs Htghryqy & HbrotualColTmbslon spproval
(it appllcabtc)
Item
r. Eelldi!
3./ GE.
Check Below
3.2 R istarad Homg I Contraclol:
NotAeplcrbb A
ComFan, Xrha
Address
signatuG TBhphao.Sl*$!m OsE
Sactlon 4 " Worlt€rs'nsurErnce Afndavlt (u.G.L 2scS
ailapplicationorkersCompensationnranceaffidavitmusta0dsubmicomplettsdttedthiswithFUrerhprovldewillattldavi{rssult then ialden the rssuan@ thofs buil ermit.Pding
SignedAffidavitAttached yes No..........
nstruc on Ss ices for Bufidings and Structurss Subiect
CMR 1 1 o (conhinlng m0re than 35 000 c t.ol enclosed space)
Arlr ol F.FsEbflty
Section 5.3 Gan8ral Confador
Pe.Ban Ro
SlgnrtotB
Not&dh8bt! O
Section 5,1 ArchltsE
mrlFr..t&O
Eegistalllon Nl,ltlr
T€l6phono
N.m. (8.91;tr.ntr!
Slgnalurq
Addres9
Erpi6tbn ore
Section 5.? R PrDlesslonal s
At!. ol AE5lorElraiy
R.gtnn[qn ftmb.t
s)
Xattra
EJqirdtioo oat!
Tslopt|oo!
Xrllr.
SlgnqtJrD
Addrpsa
&!i d Rlsrdbllty
FrglCnlhn Nur6-
Tslrphoni
Xrrlit
SignaUr!
Addres.
Ediallon oel!
Arta 0{ AEspo.BiU&t
Fogl$raton Mrnbs
si I ?e
Ha.ttl
ExpL.tloo Elat!
Fogislrathn Nut'$cr
betoof
AddrBas
Adrtr€ss
v6 ?47ry6Ialopnor
DEMO LITI
BUILDINGDEPARTMENT
ON DEBRIS DISPO AX'F'II)AVIT
Pursuant to M.G.L. Ch. 40, g54 and 7g0 CMR _ Section 105.3.1. #4.
i hereby certi8/ that the debris resulting from the proposed work/demolition to be
conducred at 4tL
WorkAdd
Is to be disposed of oat the following location:
SAL
said disposal site shalr be a ricensed sorid waste facility as defined by M.G.L.ch.111,91504.
tL'b- z?
S of Application Date
Permit No.
gTowN oF YARMOUTH
1146 Route 28, South yarmouth, N.4A0Z664
508-398-2231I ext. 1261 Fax s08-398-0836
Office of the Builtling Commissioner
\\rorkers, Comp
The Corzmonwedlfh of Massd"c.h usetts
D ep arffilefi of fnd.astrial AccidentsI Congress Street, ,guite 100
B o sto tq lt:tA 0 2 I I 4_20 I 7
t1'w4'mass' Eov/diaensatiotr Insur;uce A-ffidavit B-rild$is,tg6r1.rctrrs/Eleit.icianslplumbers.TO BE FILED WITH TIm PERI,OTTTNC ATITHORITY.ti
Nafne lBusio"sdo.ghizatioE{ndividual):P
Address: [4t0 d.6LA q
City/Slzte/Zip ,.\,L Phone #:fi1-
applicEr that chccks box #l must ais! fil out the sedion bElory showing treir vorlcers ' oompcrrration policy inforrnui oo-Horurowarrs who submit drs a6davit indicating thcy arc all wo.k and then hirr outsidc contractoB must stibmit ! new afidavit indicrding suct!
doingtonmctors that chcck this box must attachcd an addltional shect sbowiog tl6 lstEa ofthe sirLcontr-aatoB andcnlployccs.
t
l.!,!rn a crnploycr with cmployEes (tuU and/or p&.l-time)..l.MI rm-a solc proB ic& or parhcrship eM havc no cmployecs working for me in_ aay capacity. [No workcrs'comp. irsurancc requiri.):.! I am a homeomcr doing work rryself [Noworke$, comp. irrsulanc. Equired.] Ia.E I snr a horbeowrEr aDd $,il bc hirinE cr- c*.,rc rra u conta-cror:1,;;-#".m;mfi"ol5ff:my propEny. r vil
proFflclors with no arDgloyccs
reyou an employer? Clcrk th. app.oprilte bor
hirEd5altlaceocralconSactofandhaveI tlre sub-contrdctors lisrcd dre0n attached shcetIhsub-contractors Endcmployecs havE woak!rs coltp.
6.aarctr 0ncorporati sand oJ[hav edexerch dtheir ofghlexem!doa MGLpcrand52,),have cmpl Il.lo p.lnSUtaDc!rtguird.l
Type of project (required):
7. I New mnsructiou
8. f] Remodeting
9. D Demolition
l0 fl Building addition
I I . I Electrical repairs or additions
12. I Plumbing repairs or additions
13. I Roofrcpain
Othet *W tD'ltc'14.n
I om ai ehplolet thct is providing workersinforn ation-
dt.v tbe $ortcrs'@nlP,icy lurDb€r.
stato whethEr or lot $ose estr'ties havc
' compqsddon tnsarotefor nzy ettEloyear_ Belou, b the pobq ontjob site
If the sub.ooDtra.toB h.av
Insurance Company Namc:
Policy # or Self-ins. Lic. #:
Job Sito Ad&ess:
Athch a copy ofthe workers ' compensation policy d
Citylstardzip
eclaration ptge (showing the policy number and expiration date),Fai]ure to secure covemge as required under MGL c.152, g25A is a crimioal violaion punishable by a fine up ro S1,500.00and/or oDe-yeat noprlsoruDefi, as woll as civil penalties in the fonn of a STO? WORK ORDER and a fine of up to $250.00 aday against ttre violator. A copy ofthis stat€metrt may be forwarded to the Office ofInva*tigatious ofthe DIA for insurancecovorage verification.
I do hereby the and penalties thd llre Womlation provided above is true and cortecl"of perjury
-b-2,
1' Board of f,ealth 2' Btdlding Deparknent 3. city/Town clerk 4. Etectricql lNpector 5. plutrbiug Inspector
Pcrmit/License #
Phoue #:
Otjcial use anJy. Do not wtile in this qreq" to be conptered b! ci? or town ofJictaL
Cortact Person:
Issuing Authority (circle one):
Cit5r or Tovm:
Expirxion Date:
E
iEEa
lEEE
-tiEE
.n9::E! ffEE 5P i=
: EE:;!.93;q
i$EEEi p t eE
: EE=E a.q olir€=-
: I gE
iEEE
fi
115 -1t'
ROUTE 28
E
I
!
&P
,.f o
r,8
?
sL
J
r
fl,
cs-083904
RAYMOND
1410 N sTH
HARTSVILIEaC 29s50
Etpires: 06/30/2024
rYyArIgIREET
'. s'
'l!7rl
t v,ti\.r)'
C.lr.:,ti3starcr ..)'n;ZaL
JHE c.oJvrrr,roNwEA.r" o, ,noaa,c;ru"E" --uniceofconsume. Affairs a eusiness neguiatlnHOME IMPRO.VEMENT CONTRACTORTYPE: lndividuatReqlsJEtoh Exoira{oh
_ llruJo) 111W2024
RAYMOND WYATT
[7---z *,r-/4*4
Undersecretary
Registralion valid for individual use only before the
expiration date. ll found retum to:
Oflice of ConsumerAlfairs and Business Regulatioo
100O Washington Street - Sulte 710
Bosiofl, MA 021tI
Construdion Supervisor
. Urrestricted --Buildings ot any usggrou-p which containress than 35,000 cubic feel lgsl qibi; meiers) ot enctoiedspace.
u(/"f/-, /)\o$l-
Fa ure to possess a current edition ofthe Massachus€ttsState Building Code is cause for revocation of this ltcense.. Fa! intor.,::igc, rbcljl r.hls l!€rseCall 1617,1 721 _3200 ot visit www.nrass.gov/dpt
Not vatld without signature
RAYIVIOND WYATT
1410 N. 5TH ST
HARTSVILLE. SC 01610