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HomeMy WebLinkAboutBLD-23-005737 expired tX"R e tc I • 3,-,- . 1 : l . , , A Dr, ,.. , ,,, ov•Yq,q BUILDING PERMIT APPLICATION . ,.. APPLICATION TO CONSTRUCT REPAIRT RENOVATE , CHANGE THE USE,OCOUPANCY OF 0 O OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. I F Town of'Narmouth Building Department -! .ir�r Mt rv� i ».TT.�.z�, ay'�'3`'�-•e,.•" 1146 Route 28 • larrnottth, MA 02664-1-492 -- - . _..-_! Tel: 508-398-2231 ext. 1261 Fax 508-398-0836 ,, 1, Office Use OnlyPlanning Board Information Assessors Department Information: Perilltt hQ —2 3_°L15,� 1e Permit Fee $ Plan Type Map Lot Endorsement Date / (50 Recording Date New Deposit Rec'd. $ (�(� 'Date Plan No. 1.4 Property Dimensions: Net Due $ Other Lot Area(st) Frontage(ft) Lot Coverage _ Building Permit Number This Section for Office Use Only Date issued: Signature: . Certificate of Occupancy Building Official Date' is le not required Section 1 - Site Information 1.1 Property Address: / n1.2 Zoning Information: } Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided ./. / / ` - _ / 95b ;. 1.4 Water Supply(M.Q.L c.40.S 54) 1.5 Rood Zone Information: Comments Public r< Private Zone: �'. BFE: Section 2 - Property Ownership/Authorized Agent 2.1 Owner of Record: 5 /H Z. LC. — suy) .�i -J 1no42at .2/4 /20UTUB 2S'1 J,e7I2_,ivr&0 ' j 11;71 -- Name (print) t Mailing Address: halal Y 4-1,pj-tQ iAl0 y,,r,e, .1 -_ g boil-IL r'/-1`S t') L.- & ) -7 -7 g r c;`4t VS eo uvx Signature Telephone Telephone Email Address: / 2.2 Authorized Agent: /191~1 lU /15r '` -, I S-1y1i i!-t 3-r. /209Di 744 i y, i ofk,-V Name(print) r Cp i Mailing Address: f r • ilG ) iyr � 11s4-'�'- CU 11 Sig nature Teleptibne Fax • - Email Address: 1 Section 3 - Construction Services , 3.1 Licensed Construction Supervisor: Not Applicable i] C'M L)1U iI61"f2-` , V r / License Number Address,. I ♦ ; • ` 7,4 1-7zY-2S yyat5-"'x'+ ,co lrt Expiration Date Signature Teleph e Email Address: 1-72-f o /2_o_Z3 r • 3.2 Registered Home Improvement Contractor.I Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone Section 4-Workers' Compensation Insurance Affidavit(M.G.L c. 152 S 25C(6) I 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 ..bom No Section 5 - Professional Design and Construction Services-for Buildings and tructur enres Subed space) ject to Construction Control Pursuant to 780 CMR 115(containing morean Section 5.1 Registered Architect I Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date signature Telephone Section GG5.2 Registered Professional Engineer(s)I �) (. l / /-S- CC � IL—_� /1 ---'— r ^� Area of Responsibility CAW' Name Tz / J I e,) ,,} .f ��} rj ��j �� �-t'�Jf '�� ��re s8;'?2'phone signa ure �-' Area of Responsibility Name Registration Number Address Expiration Date Telephone • Signature Area of Responsibility Name Registration Number Address Telephone Expiration Date Signature 1■ Area of Responsibility Name Registration Number Address Expiration Date Telephone Signature Section 5.3 General Contractor I Not Applicable ❑ Company Name t J )/( erson Responsible for Con Wction 1.)/ 1l 0/S-s L , Telephone Signature v ' ; Section 6 - Description of Proposed Work(check all applicable) New Construction ❑ (formuttlple family only) No.of Bedrooms I (for multiple family Doty) No.of Bathrooms Existing Bldg. ,4 Repair(s) ❑ Alterations J Addition ❑ Accessory Bldg. Cl Type Demolition Other Specify: 1:xfS}I . Lesko.py Brief Description of Proposed Work: _ ,12,2AvNov. Ext`S r�te- P y, �r�r �Ld o in`e ,�+ y�Cuz�) ''{-G- U . 5 a 'r) C�t—'n t�,7c 2 pLcr n,a._ a be- - 4—3- 23 Y.y hi i 54- Section 7- Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-t Q A-2 Q A-3 0 IA ❑ A-4 ❑ A-5 ❑ 1$ Q B BUSINESS ejA, 2A Q E EDUCATIONAL 0 29 Q F FACTORY ❑ F-t ❑ • F-2 Q 2C Q H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ 1-1 p 1-2 a 1-3 ❑ 313 ❑ M MERCHANTILE ❑ 4 Q R RESIDENTIAL ( R-t (2t R-2 Q R-3 ❑ SA ❑ $ STORAGE ❑ s-1 ❑ S-2 0 56 U UTILITY ❑ SPECIFY: u MIXED USE ❑ SPECIFY. S SPECIAL USE ❑ SPECiFYc Complete thlssection if existing building undergoing.renovations,additions and/or change Iri use. Existing Use Group: R ' Proposed Use Group: Existing Hazard index 78a CMR 34 Proposed Hazard Index 780 CMR 34 2-- Section 8 Building Height and Area j' ,/,-- l�x�S�-► Bulding Area Existing(ii applicable) Proposed Number of Roots or stories i C include basement levels Floor Area par Poor(sf) Total Area All Floors(sf) Total Height(It) 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 CONTRACTOR APPLIES FOR BUILDING PERMIT I, AFt s,4 2 1,5 �'} I_.... , as Owner of the subject property, hereby authorize IM-L 1 tJ lei,sTlL to act on my behalf, in all matters relative to work authorized by this building permit appljcatio Signature of Owner LI 1 Date 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. 0 Repair(s) ❑ Alterations 0 Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: ekr5.`7.- C trspy Brief Description of Proposed Work: r?X t`s., �a P y rtyx$1(-e C 4,1 ca n'� c.,�ti Y` u L) TU 7e r e_ V`1 p��� lcr r( � 4, - ,. h i-r 0-3'(1 H Section 7 - Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A-4 ❑ A-5 ❑ 1 B ❑ B BUSINESS _ 2A ❑ E EDUCATIONAL ❑ 2,3 ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C a H HIGH HAZARD ❑ 3A 0 I INSTITUTIONAL 1-1 CI 1-2 I] 1-3 38 M MERCHANTILE ❑ 4 R RESIDENTIAL R-t R-2 Q n-3 ❑ 5A I] S STORAGE ❑ s-i (3 S-2 0 5e j. U UTILITY SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE 3 SPECIFY: Complete this.section if existing building undergoing.renovations,additions and/or change Id use. Existing Use Group: R Proposed Use Group: 14 A J ,.- Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 f Section 8 Building Height and Area • i //9- 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....).°° I SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT A 14tu/4 /2. F-,fq I < t_ , as Owner of the subject property, hereby authorize /)Y lr ) ?-) )�4i_ I' CI to act on my behalf, in all matters relative to work authorized by this building permit ap licati n.Q 4 Z A'` ' Date Signature of Owner • SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION dfil L 1 tl1 Y 1y} , 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. l lr i Al Mi 5 rt�_� • Pnnt Name / it//// � / ems-, /P' 2''27, 'Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building /l 0 (6O -.-e-�' 1 2 Electrical IJ oc - 3.Plumbing/Gas . 4,Mechanical(I-{VAC) 5.Fire Protection `1 t t7 U - 17.Total Square FL ltornew smtaims&additiorel f S'a6) .5 Check Below [] Conservation-Commission Filing (if applicable) (] Old Kings Highway&Historical Commission approval (if applicable) The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 r, ''� www.mass.g ov/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): /7,7/47' y /9 S D - Address: 31S 1.j City/State/Zip: )2 T-')/ -J4 n (9//4r7 Phone#: 7 g 1 - 72Y- 2-A , i Are you an employer? Check the appropriate box: Type of project (required): . am a employer with (o employees(full and/or part-time).* 7. E New construction 2 I am a sole proprietor or partnership and have no employees working for me in ca aci8. [ Remodeling an y p ty.[No workers'comp. insurance required.) 3. I am a homeowner doing all work myself. t 9. ❑ Demolition _ y [No workers'comp.insurance required.) .�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 1].[ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.[I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp. insurance.1 13-[Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box ii l 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: 0 Y2 I=b L. 11P,vV) k'n(.t'f(,w>9-L. Fl ag IT-15U P-►)N F 1.7 U31rt"19,31.4 Policy#or Self-ins.Lic.#: VJEJ 27 q/s Expiration Date: - ( - 2.b 2LJ Job Site Address: 21 t (Z u U T'C: , Z SST y,q-21v1 o lA p..gity/State/Zip: y 9YLr,,70c, f ta-6 z‘7 3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirItion 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th aims and penff hies of perjury that the information provided above is true and correct. Signature.: /U �� Date: -/2 . 21) Phone#: 7 g/ - 2S L Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Phone#: Contact Person: TOWN OF YAAR OUT . 1146 Route 28, South Yarmouth, MA 02664 5 -39 -2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G. L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5 I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 2 l /2 T. '2-$ / 'a y)v10 u-/4 J IM )a- Work Address Is to be disposed of at the following location: /1/.V675514 1)1 5p o 5 AL 2 / O 1_1 5 Hwy 5? FiaLhou-0.4. , ,nA- 62-53 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 4, I - 2o3 Signature of Applicant Date Permit No. ...•.41 MISTRYAS01 RCORSON A R� CERTIFICATE OF LIABILITY INSURANCE DATE DIYYYY) 4/12/2023 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 CONTACTNAME: J A Corson Insurance Agency PHHONpvc,o E,d): (781)246-5077 I (NFC,No):(781)246-2611 380 Lowell St E-MAIL #202A ADDRESS: Wakefield,MA 01880 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Graphic Arts Mutual Ins Co 25984 INSURED INSURER B:Norfolk&Dedham Mutual Fire Insurance Company 23965 MISTRY ASSOCIATES INC INSURER C: 315 MAIN ST INSURER D: READING,MA 01867 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. ADDL SUBR POLICY EFF POLICY EXP INSR TYPE OF INSURANCE INSD wvD POLICY NUMBER IMM/DD/YYYYI (MMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR 5013959 2/24/2023 2/24/2024 DAMAGE S l RENTED PREMISES(Ea occueence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ — A AUTOS ONLY AUTOSULED BODILY INJURY(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$ $ 13 WORKERS COMPENSATION STATUTEPER 1 I ERH AND EMPLOYERS'LIABILITY WE127918A 5/1/2023 5/1/2024 1,000,000 ANYA�p PROPRIETOR/PARTNER/EXECUTIVE Y 1 N E.L.EACH ACCIDENT $ (Mandatory in NH)EXCLUDED? N/A E.L.DISEASE-EA EMPLOYEE $ 1,000,OOD If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation renewal of policy term 05/01/22-05/01/23 216 Main St/Rte 28,Yarmouth MA 02673 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. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE • .).4Lill I— ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 0+�2^ a S \ mac % §J e < . . . . 2 \ }\{: . \ 2 / 02� z/ 2KK �. y 22\ < g t \ t= ) \ < \ � � c LE5 ccr � Eo 0 § /� ° �k/ k oa$ �Lw g » z�= § 2 �m§ § km� \ > � 0 � U 4/21/23,7:25 AM Mail-Sears,Tim-Outlook 216 Route 28 Sears, Tim <tsears@yarmouth.ma.us> Fri 4/21/2023 7:25 AM To: nalin@mistry.com <nalin@mistry.com> Nalin, I have reviewed your application and there are some items needed. Health Department sign off 2. Water Department sign off 3. Fire Department sign off 4. 2 copies of plans in 1/4" scale size 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 CBO Deputy Building Commissioner Town of Yarmouth 508-398-2231 Ext. 1259 mailto:tsearsPyarmouth.ma.us https://outlook.office.com/mail/sentitems/id/AAQkADE3MDQ5NWZmLTkOYzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQAJgSISLkrIZFuS2WoWVd... 1/1 4„fm* • TOWN OF YARMOUTH HEALTH DEPARTMENT o PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: 9,i 4/1_5/, 4e..---T-67 2� Proposed Improvemer}t: R G, .1f/�. '4'/ G ' i°p- /e TLj e" /1,�'�/� Applicant: (52,///764_ 412" ram,` Tel. No.: ( .5 e. Address: 2/' 2,8 Date Filed: 0 00c,ef? **If you would like e-mail notification of sign off,please provide e-mail address: //-146 1..- G(/J4''17/ c2 Owner Name: 5 WV/1/ L4 Owner Address: /2 yy e6 Ccpil/ Owner Tel. No.:693697 96 a. 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, RECEIVED and septic system location; APR 2 0 2023 (2.) Floor plan labeling ALL rooms within building (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:. } DATE: 6/1—diej. PLEASE NOTE COMMENTS/CONDITIONS: