HomeMy WebLinkAboutBLD-19-006589 UNIT T F
, ov•YqR BUILDING PERMIT APPLICATION
\� APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE THE USE,OCCUPANCY OF,
C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
O ; y Town of Yarmouth Building Department
..�rracticcs
�...�,,,.•* 1 146 Route 28 • Yarmouth, MA 02664-4492
Tel: 508-398-2231 ext. 1261 Fax 508-398-0836
Office Use Only Planning Board Information Assessors Department Information:
Permit Np,30 Plan Type Map Lot
Permit Fee $ Endorsement Date ?7/ 9/e
G� Recording Date New
Deposit Rec'd. $ Date Plan No. 1.4 Property Dimensions:
Net Due $ Other Lot Area(sf) Frontage(ft) Lot Coverage
This Section for Office Use Only
Building Permit Number i 2 Date Issued:
/ / . Certificate of Occupancy
Signature:
Bui ng Official Date is is not required
Section 1 - Site Information MAY 1 t )019
1.1 Property Address: 1.2 Zoning Information:
/ 1(i_k,'i'e 13041 a r ,P 3 7' CSC qA3
'O /!lciff e IL) 7r--1,\ 19,2b&r 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(M.Q.L c.40.S 54) 1.5 Flood Zone information: Comments:
Public Private Zone: BFE •
Section 2- Property Ownership/Authorized Agent
2.1 Ow er of Record:
Q. -Da\ icvkviw \Es -?>32 w-t-t -'S - cW ll
/Name(print) Mailing Address: 3!v 1 � ; �c G2-4� 1
Si- :, ._ •.„�/'!-- - , -_-. _ Telephone Email Address:
2.2 Authorized - •ent Jy\Q.'NU c.Vv'Zk ( ` O.I. M
14,A,z_ey'< C , AV.0}ro A b(4/1/--9_5r ig 6‹.9A'(PAte''i Ail-14
Name(print) I, Mailing Address: / 1' pot iv,69 te).64 0/'6
,...---' Vt44,.. 1-' , 0- feY204-654-, In-i q(077 '
Signature Telephone Fax Frail Address !
Section 3 - Construction Services
3.1 Licensed Construction Supervisor. Not Applicable ❑
License Number
Address
Expiration Date
Signature Telephone Email Address: .
, _r
' ; ; Section 6 - Description of Proposed Work(check all applicable)
New Construction ❑ (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:
1
Brief Description 9f Proposed Work:
(f&IR z:- ((n a) 4, / d0r... ,l61 / L'ri
IAA / rZes a zy, '0`0 d F'c-6ty O ri, �2.Yil P 4/1
C.. -Pe COD COOk`/
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 ❑ 1 B ❑
B BUSINESS ❑ 2A
E EDUCATIONAL ❑ 28 ❑
F FACTORY (❑ F-1 ❑ F-2 ❑ 2C ❑
H HIGH HAZARD 0 3A ❑
I INSTITUTIONAL 0 I-1 D 1-2 O I.3 0 38
M MERCHANTILE CI 4
A RESIDENTIAL U R-1 D R-2 0 R-3 ❑ LA ZI
S STORAGE ID S-1 D S-2 D 5B
U UTILITY
_ CI SPECIFY:
M MIXED USE D SPECIFY:
S SPECIAL USE SPECIFY:
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(st)
Total Area All Floors (sf)
Total Height (ft)
Section 9 - STRUCTURAL PEER REVIEW (7B0CMR 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_
I, Q .. & 0 V L , s Owner of subject property,
hereby authorize ( `' VI Gt('g l 1 C'—e,>�ll to act on
/ my behalf ' I matter lative to work authorized by this building permit application.
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Signature Owner O to
- _r A
r '
SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION ,
I, e il G1 P \. C.
''4,i?.G' as Owner/Authorized Agent •
`
hereby declare that the statements and information on the forgoing application are true and acurate, to
Jthe best of my knowledge and belief.
Signed under the pains and penalties of perjury.
ale 10I,^.,f✓ W' ( PPV.e iy) sil
Print Name
V.../127/,`Gz3:"" 0 fo,DP.0,, , „
077/-,. /1(i
Signature of Owner/Agent Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
a Electrical
3.Plumbing/Gas
4.Mechanical(HVAC)
5.Are Protection
\ w 6.Total=(1+2+3+4+5) /}. �
\V 7.Total Square Ft.(larm smctnes&amitiaet 114 0(/
Check Below
0 Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(if applicable)
,. ash,
TOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant: �,J ,
Building Site Location: 2 3 T (c)h) 4'4 ,i �'� cep '(� irnz LA°d 0;c)0
Proposed Improvement: . I .. ' t /.. 2 ./.
Applicant: (I ,e Tel. No.: ' /&"7'74,
Address: 2,k� Filed:Date c f4./ f Cr'
**Ifyou would like e-mail notification of sign off,please provide e-mail address: Co;AR6aacaPC P 5 A 97,„e/9,,,t,/,)G9Jrv,
Owner Name: 2P t2 PI P U- ( PP4 1 SG y'
Owner Address: / 7 i y , fit�c2 � Owner Tel. No.: e_
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,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
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:
PLEASE NOTE
COMMENTS/CONDITIONS:(S: C r1 ` ;t / f) kevj
/n
The Commonwealth of Massachusetts
1111717 1, Department of Industrial Accidents
M"= l� 1 Congress Street, Suite 100
Boston, MA 02114-2017
s�. www.mass.gov/dia
alp
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ,�' ,e „.7
Address: t% 1 Ni;
City/State/Zip: 5 a> '`f ,z, ,, ✓ �' � „L Phone #: ' 4 ? 7
Are you an employer? Check the appropriate box: Type of project (required):
1. 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 8. 7 Remodeling
any capacity.[No workers'comp. insurance required.]
9. ❑ Demolition
3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t —
10 Building addition
4. 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 1111 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp. insurance.1
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. 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.
: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 underthe pains and penalties of perjury that the information provided above is true and correct.
,c,101.?
Signature: Date:
Phone#: 9 7776
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#:
MGL AND FIRE
TOWN OF YARMOUTH
j REVIEWED FOR CODE COMPLIANCE.
It
4
ERRORS OR OMMISSIONS DO NOT RELIEVE
•
THE APPLICANT FROM THE RESPONSIBILITY
` OF"AS BUILT" COMPLIANCE.
ow, DATE: .f(G-l9
//_€' C # ?? . I1t1QK
INSPECTOR
YARMOUTH FIRE PREVENTION
New Business Transmittal
Project Name: Cape Cod Cookies To Go Address: 23 Whites Path Unit T
Contact Name: Kenneth Peterson Phone: 508-241-0776
IY N NA Subject Regulation
ES 0
X Building Numbers MGL Chapter 148;sec 59
X Fire Lanes 527 CMR 1;22.3
X Extinguishers 527 CMR 1; 13.6,Chapter 148;sec 28
X Maintence of any equipment,system relating to 527CMR1 1.1.4
Fire Protection.
X *Hazardous Materials Storage 527 CMR 1;60.1
X Emergency Plan Required 527CMR1 10.9.1
X Commercial cooking,Hood systems 527CMR1 50.2.1.1
X Commercial Cooking Hood Systems Cleaning 527CMR1 50.5.4
X *Commercial Cooking Extinguishment System 527CMR1 50.4.3
X *Candles,open flames,and portable cooking 527CMR1 17.3.2,20.1.1.1
X Blocking electrical panel 527CMR1 10.19.5.1
X Blocking exits 527CMR1 14.4.1
Extension cords shall not be used as a 527CMR1 11.1.7.6, 11.1.7.1
X substitute to permanent wiring
X Limit storage heights to 24 inches below 527CMR1
ceiling without sprinklers 18 inches with
X Maintain Aisle width of 36 Inch's(3 Feet) 780CMR 1101.1
X Storage inside/outside Buildings 527 CMR 1; 10.19.4,4.4.3.1.1,19.1.2,34.1.1
X The right to inspect MGL Chapter 148 Sec.4
X *Upholstery 527 CMR 1;20.6.2.5
X *Trash Containers 527 CMR 1; 19.1.1, 1.12
X Any Hazard to the Public Chapter 148;sec 28
X *Curtains,Draperies,Blinds 527 CMR 1; 12.6.2
Description of planned project/other requirements:
The YFD support the application, subject to applicable submissions,permits
and inspections.
A Permit from YFD is required any time a fire protection system is shut down.
* YFD permit required-depending on occupancy and submittal
Plan Reviewed By: Captain Kevin Huck Date: 05-16-2019
Copy for Applicant = Copy to Building Department Copy to Fire Prevention I I
Entered in Firehouse r—J Final Inspection
0 I ;
RECEIVED Waii CZ Cal)
MAY 1 62019 !2` 4e1Tiket.CM
2,0
HEALTH DEPT.
TOWN OF YARN101-3Til
REVIEWED FOR BUILDING AND ZONING CODE CON1PLL
ANC:E. ERRORS OR OMISSIONS DO NOT RELIEVE TVE
APPLICANT FROM THE RESPONSIBILITY OF 'AS BUIL:"
COMPLIANCE.
DATE:
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