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HomeMy WebLinkAboutBLDC-23-99 I � et ferlit-i?L- of Y�R BUILDING PERMIT APPLICATION 1 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF, , - It _C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. Town of-Yarmouth Building DepartmentEaM7,-.Z..CC �: �3a4'..- ` 1 146 Route 28 • Yarmouth, MA 02564-4492 Tel: 508-398-2231 ext. 1261 Fax 508-398- 836 Office Use Only Planning Board Information Assessors Department Info ti� +� • Permit No. -1� r (Date Plan Type Map Lot Permit Fee S'V� Endorsement Date NOV 31 2023 Recording Date _..- Deposit Rec'd. $ 6d Date 1.4 Property Dimensions: FAY iLDING DEPAR rNIE N r I Plan No. — Net Due $ -�� Other Lot Area(sf) Frontage(ft) Lot Coverage A 0 1) CI I JZ5 /2 L This Section for Office Use Only Building Permit Number: l Date Issued: lt ' ))5 ) Signature: • • =�� 1 - L\_�� Certificate of Occupancy Building Official Date is Is not required Section 1 - Site Information' 1.1 Property Address: / 1.2 Zoning Information: CA 1 OM 2 So � 4 iul/11eR4, 1 1/110 0.24)0AZoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Required Rear Yard q Provided Required I Provided Required Provided 1.4 Water Supply IM.G.L c.40.S 54) 1.5 Flood Zone information: Comments Public Private Zone: SFE Section 2 - Property Ownership/Authorized Agent /2.1 Owner of Record. I 1.1Y) MC/0 )c2 r..&l'turt tl c Name ,Lq ) Mailing Address: - tv:0 4 L 7C4 Svc-g01- 2) Sot -to'i-zu u ra < < 'l S' natur Telephone G' r 1 d �i�jj,�"'ir(G (�� ,.,. Telephone % 2 A orized Agent Email Address: _ rocfra.h h&. - ' 4 risk c —P AM ri b-/ r >r <S'/irts Inc . 65 w,-j't w17-1-F 9mG.>l ' CD, / Name(print) Mailing Address: Signature Telephone Fax Section 3 - Construction Services Email Address j 3.1 Licensed Construction Supervisor: 0;n1 c,n W hi }-C{�.� Not Applicable 1 �s �soo� I l y✓� k r rv� cki 60;G o�3 License Number Address Signature 77 - �i1 '// Expiration Date Telephone Email Address: PO fin&-t) gp10hi I4k1, (7a SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION , I, , 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 Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building HOC,, 0 2.Electrical 3.Plumbing/Gas i4.Mechanical(HVAC) 5.Fire Protection 9.Total=(1 +2+3+4+5) • 7.Total Square FL ltacnew stnc¢nes&additixe) Check Below ❑ Conservation-Commission Fling (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) Section 6 - Description of Proposed Work(check all applicable) New Construction 0 (for multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: I Brief Descriptio of Proposed Work: haoi1 in Gown tA;alf ,.) sow Beret will. (WWp!. Shed-Pock ROO"I^ I J Section 7- Use Group and Construction Type I Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 0 A-2 0 A-3 ❑ IA ❑ A-4 ❑ A-5 ❑ 1 B 0 B BUSINESS ❑ 2A 0 E EDUCATIONAL ❑ 2B ❑ -F FACTORY ❑ F-1 0 F-2 0 2C 0 H HIGH HAZARD 0 3A ❑ I INSTITUTIONAL 0 I-1 ❑ 1-2 0 1-3 0 3B ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL D R-1 0 R-2 ❑ R-3 0 5A ❑ S STORAGE ❑ s-1 ❑ S-2 0 5B ❑ U UTILITY , SPECIFY: • M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this.section if existing building undergoing renovations,additions and/or change hi use.I Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 78D CMR 34 Section 8 Building Height and Areal ' 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 CONTRACTOR APPLIES FOR BUILDING PERMIT / , as Owner of the subject property, ` / hereby authorize to act on VVV my behalf, in all matters relatito rk authorized by this building permit application. Signature of Owner Date r• 3.2 Registered Home Improvement Contractor. , Company Name Not Applicable ❑ Address Registration Number Expiration Date Signature Telephone 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 t 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 ❑ 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 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 Name Person Responsible for Construction Address Signature Telephone Acc DATE(MM/OD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/3/2023 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 CNAME CT Ken Christianson The Driscoll Agency PHONE FAX 141 Longwater Drive,Suite 203 uvc.No.Exth 781-681-6656 (ac,No):781-681-6686 Norwell MA 02061 Ess: kchristianson@driscollagency.com INSURER(S)AFFORDING COVERAGE NAIL INSURER A:Continental Western Ins Co 10804 INSURED 3100 INSURER B:Union Insurance Company 25844 A.P.Whitaker&Sons, Inc. 652 West Center St. INSURER C:Acadia Ins Co. 31325 West Bridgewater MA 02379 INSURER D:Travelers Prop.Cas.Co.of America 25674 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1408308830 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXPW LIMITS LTR *MD WVD POLICY NUMBER (MDD/YYYY) (MWDD/YYYY) A X COMMERCIAL GENERALLIABIUTY Y Y CPA5144040 3/31/2023 3/31/2024 EACH OCCURRENCE $1,000,000 GE TO CLAIMS-MADE X OCCUR PRREM SES(EaENTED ocaxrence) $300,000 MED EXP(Any one person) $15,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECa'T LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER $ B AUTOMOBILE LIABILITY Y Y MAA5144041 3/31/2023 3/31/2024 COMBINED SINGLE LIMIT $1 000 0� (Ea«a.idrirt) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ D X UMBRELLA LIAB X OCCUR Y Y CUP-5W798346-23-NF 3/31/2023 3/31/2024 EACH OCCURRENCE $10,000,000 EXCESS LAB CLAIMS-MADE AGGREGATE $10,000,000 DED RETENTION$ $ C WORKERS COMPENSATION Y WCA5144044 3/31/2023 3/31/2024 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 A Installation Floater CPA5144040 3/31/2023 3/31/2024 Location/rransit $50,000 Leased Rented Equipment Per Item $125,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Sample Certificate x x* AUTHORIZED REPRESENTATIVE�NT tie* ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • The Commonwealth of Massachusetts 1}:-_ :=.'t Department of Industrial Accidents 1_ 1 Congress Street,Suite 100 `:-` ► -1 Boston, MA 02114-2017 - wow mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ADDileant Information Please Print Leziblv r Name(Busimess/Orpnizationllndivi ival): /- (�/I��y,�. 5 7 o'-' _,v'4. Address: C kk-i C 1t,\_- S City/State/Zip: ljeci- 4_12(( r— / Phone#: -' S oY G� /i r Are you as employer?Check the appropriate box: Type of project(required): 1.0 am a employer with / employees(full and/or put time).' 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 14 Remodeling any capacity.No workers'comp.insurance required.) 3.01 am a homeowner doing all work myself.lido workers'comp.insurance required.)r 9. ❑Demolition 4,01 am a homeowner and will be hiring contractors to conduct all work on my property. I will l0❑Building addition ensure that ail contractors either have workers'compensation insurance or are sole i 1.❑Electrical repairs or additions proprietors with no employees. 1 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. un repairs repairs or additions These have employees and have workers'comp.insurances .0 Roof 6.0We are a corporation and its officers have exercised their right of14.0 Other exemption per MGL c 152,11(4).and we have no employees.lido workers'comp,insurance required.) 'Any applicant that checks box Si must also fill out the section below showing their workers'compensation policy information. t Homeowners wino 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 mint attached an additional sheet showing the tame of the sum and state whether or not those entities have employees. If the 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: /C/a; r Pr $N 5 Policy#or Self-ins.Lic.#: W CI. .571/4(0�6( Expiration Date: 5 3(2 4i Job Site Address: 9c/ nio,) _c-;,riA-y/L? uye- fitCity/State/Zip: Attach a copy of the workers'compee . do policy declaration page(showing the policy number and expiration date). Failure to secure coverage as re u""(under MGL c. 152,*25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonsn n�j`!ri even 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 coy} this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification; I do hereby card , t#nder-th ,sins and penalties of perjury that the information provided above is true and correct. ate: Phone IS: ` Y-GC77 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other ' Contact Person: Phone#: 1 i TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 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 g conducted at 1.i 1l1Y/ Zc' arm,* i)1)9 olC -1 Work Address Is to be disposed of at the following location: kW(' )I Wu-Cc( Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 1130 23 ignat re of Applicant Date Permit No. Commonwealth of Massachusetts l Division of Occupational Licensure Board of Building Re ulations and Standards Cons oif port Svssor CS-050309 x`' _ I;lcpires: 11/02/2024 NORMAN E VHITirirzdir, 84 PLYMOU S _4: l' MIDDLEBORft M/ v ...c)7 / 3/4. 4E40.6. r - - ,. 2.91/2. br. CEILING Ilr Tilt' fi HEIGHT: & 7*-9.5" .... .... CEILIN To, ed 6110'4 / HEIGHT: 176 6 tAel„ Art4--4 • ;\., f 7*-951' co CI TYPICAL , , / & HI BEAM / ..... / HEIGHT: 71-4" ' TYPICAL 0) / 7',- n BEAM /._ .2, , _yv , w4 HEIGHT: 7' likft, 0' ,NRITItysi, — 7 4* 9' q ,,... 4*•.**,„41111, 5 1/4*., 0:6. 41111111kovii ..„....../..‘,2 9(1 .--ilitr67' 7 I tip 1 3/4. . -----, att.:2. ..t.,iiiii 9//2. *itIrt .... ......._ CEILING f I ' HEIGHT: .... /0,. . iv CEILIN • rsa' Ni. si / HEIGHT. c) i CI ' q) , / TYPICAL / HI is BEAM HEIGHT: 7'-4" / TYPICAL 0.3, 7'. , BEAM ,4153 HEIGHT: 7' . :7- ftlii ..... i c '''***........filitif ' Q //4•. ' Silk 5;.: 'I i--) nT °s G _______, t $c og. . 1 _ .� Nf i , d v-r`c N X N s J Jib VS -11 5 ri Ft L i 1 E 1. 0 it . " o)(Tice Ilse Only Y Of A\q;\ PernritM -___ a ..gip` _.. Ot •sK S i1 Amount o ,. Permit expires 180 days from c issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 961 ma 28 south yarmouth ma 02664 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: Parcel: OWNER: hanuman darshar 961 ma 28 south yarmouth i 5088012026 NAME PRESENT ADDRESS TEL 4- CONTRACTOR: A.1"S W N t ice -(` �P c SZ 1 '&,.. sr 0. . .2` '' S)°, S5Y-Claff NAME. MAILING ADDRESS TEL.ii 0 Residential EiCommercial Est.Cost of Construction S 3 Od() Home Improvement Contractor Lie.II Construction Supervisor Lk.M C S� 015-0304 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor et-i have Worker's Compensation Insurance Insurance Company Name: A-C A i->t i Worker's Comp.Police, OCA 51 4 4 0 41 _ WORK TO BE PERFORMED Tent D Duration (Fire Retardant Certificate attached?) Wood Stove Illi Siding: k of Squares Replacement windows:k Replacement doors: # ''� f 1 Roofing: AO of of Squares (0)Remove existing*(max.2 lasers) Insulation 1 Old Kings Highway/Historic Dist. in) Replacing like for like Pool fencing 1..3 *The debris will be disposed of at'. '" Location of Facility I declare under penalties of perJu ' s herein contained are true and correct to the best of my knowledge and belief I understand that any false answer(s) will be Jun cause for denial or r clinse and for prosecution under M.G.L.Ch 268,Section I Applicant's Signature._ _ Date �'-Z7—Z� —_----_/-Z ()wain*motor,for sttacAne / �_�._ Dale: ��!i ._`____�__----V---- Approved By: Date: .._..... __________ 1 Building frciaf( designee) EMAIL.ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 It of Wetlands: Yes No Ycs No