HomeMy WebLinkAboutBLD-23-005052 (Dici';'W \ - — i•`\
' a A� BUILDING PERMIT APPLICATION
rAR
{ 'tr APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF,
13 o OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
�.Tr.���rs �• Town of Yarmouth Building Department
BUILDING DEPP 4""'"'*c1P' 1 146 Route 28 • Yarmouth, MA 0266.1—E492
By` - Tel: 508-398-2231 ext. 1261 Fax 508-398-0836
Office Use Onty4 Planning Board Information Assessors Department Information:
� n Date Plan Type Map Lot
Permit Fee $ 5�3�� Endorsement Date /
Recording Date New
Deposit Rec'd. $ (1() Date Plan Na. 1.4 Property Dimensions:
Net Due $ Dther Lot Area(sf) Frontage(tt) Lot Coverage
This Section for Office Use Only
Building Permit Number: Date Issued: . '
Signature: . Certificate of Occupancy.
Building Official Date• is Is not required
Section 1 - Site Information
1.1 Property Address:
Pao,
1.2 Zoning Information:
9 Ark. / ao, Sl . `
Zoning District Proposed Use
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.4 Water Supply MALL e.40.S 54) 1.5 Flood Zone information: Comments
Public Private Zone: BFE:
Section 2- Property Ownership/Authorized Agent
2.1 Owner of Record: �� ,(
J L ) Rec (y reote-J-ko►..) -)V1 ilAc. 4,, 4 am.icc i.41> ozbbi
Name(pri t)-/— Mailing Address:
5o- - r3g-��US
Sign a Telephone Telephone /
— Email Address:
2.2 Authorized Agent:
Name(print} Mailing Address:
Signature Telephone Fax Email Address:
. Section 3 - Construction Services
3.1 Lic.nselConstrueti Supervisor. Not Applicable ❑
1,5roLvlio I"1�a.
License Number
1q So, iu S. t2¢hi i) M& Ozc i o c s-(( Os y;
Addy s(� =/ 1 / ` I /�
t_t 4(,7,05_020(1 1 jbrc✓lioI t9Qtt,W( Expiration Date
Signature Telephone Email Address:J 0 5 1'6 31 2O 2u
Inch
rG(.1 I u 10 f I '"D � 1. --1-C.A"'L-Q- .
3.2 Registered Home improvement Contractor.
Comp ny Ham Not Applicable ❑ ..
t5 r 1 o �r1 1.0
Address Registration Numb r
�
A Expiation cat
Signature / 11 D � ����
i (Telephone `j _ Zb-0706 9- c(20eq
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
Not Applicable Er
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
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
Hams Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Address Area of Responsibility
Registration Number
Signature Telephone Expiration Date
Section 5.3 General Contractor
Not Applicable
Company Hama
i
Person R��pocible for cgn�truction
Address �( 4 ,( 11
y_Z6 �—o�Il`
signs ure Telephone C�
Section 6 - Description of Proposed Work(check all applicable)
• ' New Construction ❑ (tor multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms
Existing Bldg. ❑ Repair(s) '. Alterations I
❑ Addition ❑
Accessory Bldg. 0 Type I Demolition Other Specify:
Brief Description of Proposed Work:
P iOt.c.o..A_ t'O +v w s , re 1--to Sit
Section 7- Use Group and Construction Type
Building Use Group(Check as applicapable) Construction Type
A ASSEMBLY ❑ A-1 ❑ A-2 A-3 ❑ 1A
A-4 ❑ A-5 ❑ 1B ❑
B BUSINESS 0 2A ❑
E EDUCATIONAL ❑ 2a ❑
F FACTORY ❑ F-I ❑ F-2 ❑ 2C
H HIGH HAZARD ❑ 3A ❑
I INSTITUTIONAL ❑ 1-1 O 1-2 D 1-3 ❑ 3B
M MERCHANTILE ❑ 4 0
R RESIDENTIAL ❑ R-1 ❑ R-2 R-3 0 5A
S STORAGE S-1 i3 S-2 ❑ 58
U UTILITY 0
_ SPECIFY:
M MIXED USE ❑ SPECIFY:
S SPECIAL USE 0SPECIFY:
Complete this section if existing building undergoing renovations,additions and/or change in use.
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area •
Building Area Existing(if applicable) Proposed
Number of floors or stories
include basement levels
Floor Area per Floor(sf)
Total Area All Floors (sf)
Total Height(ft)
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 OR CONTRACT R APPLIES FOR BUILDING PERMIT
I, JG".,1. 6-4( (M �(% DP , as Owner of the subject property,
hereby authorize j)/2C-1-1-1-41)----? %f t to act on
my behalf, in-alt matters relative to k authorized by this building permit application.
'5 13 43
Signature of Owner Date
•
SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION
I. J Qcn,,1 Q k/l J (1- `jCoiv , 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.
(G
Print Na
O3 / l3r/z3
Signature caner/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
` n/ 0 00
2.Electrical
' 5oO
3.Plumbing/Gas
4.Mechanical(HVAC) 19 O 0 °
5.Fire Protection y
5.Total=(1+2+3+4+5) . f 5, 500
7.Total Square Ft.,(tome.sencnnes&additiom) �J 1 z cJ 0
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable) •
The Commonwealth of Massachusetts
1 441111111== 1
Department of Industrial Accidents
1 Congress Street, Suite 100
p*=li _ Boston,MA 02114-2017
6y`�� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ll Please Print Legibly
Name (Business/Organization/Individual): (1 f`et,Ull`O £n r i f L0
Address: 1 Clt SQS3C, 1.;
City/State/Zip: gli¢.iA,\y\ /4 , 0 L(a 6 D Phone#: 11 q- Z 6 6•-020 6
Are you an employer? Check the appropriate box: Type of project (required):
1.D I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.N I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity,[No workers'comp. insurance required.]
3. I am a homeowner doingall work myself. t 9. ❑ Demolition
❑ y [Noworkers'comp,insurance required.]
10 ❑ Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
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.E I am a general contractor and I have hired the sub-contractors listed an the attached sheet 13,❑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. ld•❑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.
tContractors 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: S No 4 L M Lv i 1,1 r City/State/Zip: (l0,, nv‘.,
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 undere kilt,thepains and penalties of perjury that the information provided above is true and correct.
Si natl_ire: `` el_. Date: 0 343/2 3
Z
Phone#: -II(I-268 -O LoG
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
508-398-223!1 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 g1 N 0 r4 " L4 c w `5V S, cj 'tio" '
Work Address
Is to be disposed of oat the following location: 6,0 yo ;F: w e 5+ (2_J .1 (/J/ + ( r't
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §
6 1 (3 IZ7
Signatur f Application Date
Permit No.
3/21/23,9:38 AM Mail-Sears,Tim-Outlook
9 North Main St
Sears, Tim <tsears@yarmouth.ma.us>
Tue 3/21/2023 9:38 AM
To: braulio brito <ingbrauliobrito@gmail.com>
j 1 attachments(963 KB)
existing building evaluation.PDF;
Braulio,
I have reviewed your application and there are some items needed.
1. This building falls under controlled construction and will require the plans be stamped by a
Registered Design Professional
2. Existing building evaluation(see attached)
3. Fire Department sign off
Please submit these items for review
This email is considered a written denial of your permit application per Section 105.3.1 of the
Massachusetts State Building Code. Section 105.3.2 states in part that "an application for a permit for
any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless
such application has been pursued in good faith"
You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100,
within 45 days of this notice.
Timothy Sears CB()
Deputy Building Commissioner
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsears@yarmouth.ma.us
Timothy Sears CB0
Deputy Building Commissioner
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsears@yarmouth.ma.us
https://outlook.office.com/mail/sentitems/id/AAQkADE3MDQ5NWZmLTkOYzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQADOUFtWW3rtFpSJbCSR... 1/1
9 N Main St South Yarmouth
Main Main
21 entrance entrance
Waiting
area
Main Store
Maui Store
28 28 28
Ds.
3
9 Roc01
6
10
5 ill11.111W 5
2 8 6 4 2
11
Hoorn 01 Room 2 r4o.
22 10
5
11
Rce
6 44
10
Kitchen 8 8
5
4 Room 2 4 18
6 44 6 13
18 : Hail
10
amm=.
4 4
4 4 4 4
7 16 7 16
1
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HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: CI ti/ ill* ,u So, 5 ptizmourtf-
,Pro osed Im rovement: (61 (I 47 t e V It
wck
Applicant: COI Te4030 Tel. No.: 77-1I 3027' 0/9p
Address: Ufll`cL E (31 DA" i t}\-(tAJ163, f-{-O260r Date Filed: 03 3
**If you would like e-mail notification of sign off,please provide e-mail address:
Owner Name: (.7kl1/4.) M I C( 4L-
Owner Address: Owner Tel. No.: 608934o-46
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e.,Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
I -EU-JL ) and septic system location;
2.) Floor plan labeling ALL rooms within building
MAR 2 7 2023 (all existing and proposed)—
HEALTH DEPT. Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: �,,�,r� DATE: �,2/-a 3
PLEASE NOTE
COMMENTS/CONDITIONS:
9 N Main St South Yarmouth
Main Main
21 entrance entrance
Waiting
area
Main Store
Main Store
28 28 28
a,...
3
9 Room 01
6
10
2 8 6 5 5
4 2
11
Room 01 fionin 2
22 10
MAR 2 7 2023
11
HEALTH DEPT. Hoorn 3
6 I 44
10
Kitchen ' 8 8
5
vim.. .r.r..�
4 Room 2 4 18
6 44 6 13
e +va+� 18 4semwwn P.v m;n 4 }Ft9i
s S 10
4 4
4 4 4 4 h4aaff
7 16 7 16
Before Proposed