Loading...
HomeMy WebLinkAboutBLDC-23-46 pF.' BUILDING PERMIT APPLICATION l 2CCE0 APPUCATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE,OCCUPANCY OF, `, li y OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. F 11 . S: Town of.Y.trrnotith Building Department 4.70 1 146 Route I28 • Ytnnouth,MA 02664-4492 Tel: 508-398.2231 ext.1261 Fax 508-398-0836 PermAoII��j Office Use OnlyPlanni g Board Information Assessors Department Information: x- 6- U Date Plan type, Mao ter Permit Fee $ �t)Z, Endorsement Date / Deposit Fec'd. $(U4 Date c1 Recording Date '4 PropertyNew Plan No. Dimensions Net Due $ Other Lot Area(sf) Frontage(f t) Lot Coverage This Section for Office Use Only Building Permit Number. Date Issued Signature: ✓s'% Certificate of Occupancy. Balding tficfal Date is Is not required �I/ ) Section 1.-Site Information I 1.1 Property Address: `6 .1 PCrIf' 1.2 Zoning Information: ZZOLA \ yen r ',u,1 ( ( 6U Zoning District Proposed Use •`h 1.3 Building Setbacks(R)' _ li IF-9 Front Yard Side Yards Required I Rear Yard It Provided Required Provided Required Provided 1.4 Water Supply(M.Q.L c.40.S 541 1.5 Flood Zone information; r fir, aprrrr,m __ Public Private "fit' e- e V Zane: BFE I Section 2-Property Ownership/Authorized Agent] I ll ll"AUG j 2.1 1TOwwtner of Record[�lt p T t AUG 1 0 2023 T'``"` 'A /-J'!A I�1�E'� ' BUILDING DEPARTMENT k Name(print) Mailing A9frLsss: liture Telephone Telephone 2.2 Authorized Agent I Email Address: f 1APrli Oil,�c�e�CR1S��4C- xi N rim ) t Mailing Address: C r , ' ature ephone � Fax Email Address: Section 3-Construction Services 1 3.1.Lens Construction Supervisor: Not Applicable❑ ., 1 ii,-!'!OA GYI7 CO/U/T/ 11,4 (226 S License Number Address / - C-56 6g - (7/�)�n Expiration Date Si t e Telephone Email Address: I • /C//7I2 jr—uf?D u)u/�i r,i>L U�:_ t i)/ 7 ` ) 1111 '. t 1 , r SECTION 1 Ob OWNER/ AUTHORIZED AGENT DECLARATION I, t K ) ) AA --F '? I Jt_/ K. -- 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. • . :61 innef IL r 0(d'CAS--1 (7,; 4c, • . Print Name / r i� _ >�r �.t.�. (i;� S 0 gillL) ( 7P 7 �J S g re of Owner/A nt Date Section 11 - ESTIMATED CONSTRUCTION COSTS item Estimated Cost (Dollars) to be completed by permit applicant 1. Building - 2. Electrical 3. Plumbing/ Gas 4. Mechanical (HVAC) • 5. Fire Protection 5 0 00 ,67) S. Total = (1 + 2 + 3 +4 + 5) .ks. 7.Total Square FL (IIornew stn ctnas&additions) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway & Historical - Commission approval - (if applicable) • f • • • i I . I 1 . I . I Section 6-Description of Proposed Work(Ihecl all applicable) New Construction CI (for multiple family only) No.of Bedrooms.. I I(for multiple family only) No.of Bathrooms Existing Bldg. ® Repair(s)® Alterations 0 I Addition ❑ Accessory Bldg. ❑ Type IDemolition I Other Specify: Brief Description of P vw•osed Work: (Te le I bit-MO( 0 afIVWA IJLC�171 . ,00ri/(�1�tI �o�_ 1 el r ('.e ins(' ir,Yl ui exts� ino11, lee r1 4CeriVII.A to Section 7-Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type A ASSEMBLY ElA-1 ❑ A-2 ❑ A-3 ❑ IA ❑ _ B BUSINESS ❑ Al ❑ A 5 ❑ 1e ❑ E EDUCATIONAL ❑ 2A 0 F FACTORY ❑ F1 2B ❑ H HIGH HAZARD ❑ ❑ F2 ❑ 2C ❑ 1 INSTRUT70NAL ❑ 1l 1 3A ❑ IA MERCHANTILE ❑ El1-2 Ell-9 ❑ 38 ❑ R RESIDENTIAL 0 4 DI S STORA ❑E ❑ S-1 ❑ s 2 ❑ R a ❑ SA ❑ U ❑ 58 ❑ SPECIFY: — M MIXED USE ❑ S SPECIAL USE SPECIFY ❑ SPECIFY Complete this section if existing building undergoing renovations;additions and/or change In 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 Area I • Building Area Existing(1 applicable) Number of Boors or stories Proposed 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 kON 0(J r`/1/1�( ,e/VS6 S ,rn G. to act on my behalf,in all matters relative to work authorized by this building permit application. Signs wne / Date 3.2 Registered Home Improvement Contractor. , Company Mama Not Applicable ❑ )tern)oij rYti_ Ap't -*e_.` 1riC, Registration Number Address ! Fi 11C .0 t1^t Cot !?!l 0 Diu //' i Expiration Date Signature ,.tt -� Telephone(() �$ Luca? 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 ❑ 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 PD'7o(_/1 Cam- _//seS Ifl( Not Applicable ❑ Company Name Cy &61/✓( C/ Person RAsponAible toyConstrpction Addrest: � (c 2 6 ,K. Sign e Telephone The Commonwealth of Massachusetts i: Department'of industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 `�v www.mass.gov/dia „o Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 54?..0JuJ OU £Y rt> e.s ,fin e Address: 40 An cio, Ly\ t City/State/Zip: CM I T 1 VA OQ 63 S Phone #: C5Oe6 ES ` 0-6 Are you an employer? Check the appropriate box: Type of project (required): lk I am a employer with '-- employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 8.. ❑Remw construction any capacity. [No workers'comp. insurance required.] Remodeling 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.)t 9 ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees. 11.0 Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 13•Q Roof repairs 6.0 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 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: ROBE( - DTEf' l/)/'•� /A/S <v Policy#or Self-ins. Lic. #: 6 f !U B OG-1y oici3,23 O4%3/Z(� Expiration Date: Job Site Address: gju. pouf,_, A City/State/Zip: /Zip:Attach a copy of the workers' compensation policy declaration page(showing e policy number and �dat�� 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 untgir t e pains and penalties of perjury that the information provided above is true and correct. Signature: '\ 74/1_4__//- Date, 17g/n 4/7_OZ 3 Phone#: (sCDd n—y10 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#: • • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership,.association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and whb resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the.applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia 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 debrisff resulting from the proposed work/demolition to be conducted at Y IOi-C Il 14.l 4;7__ Work Address Is to be disposed of at the following location: VW/riot- roblin Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. )// OW1 o/ao Si ature of Applicant Date Permit No. i h• • / ?s ,::::,�•..:. o'" k :: ., se : g €€F€:€ .€w.,.��y . :-:::; ;3 � I;,;cY .4�.# s..g. - 2 z „£- t >I '.Sf..:.Y�v :i 'S' fir b 5 T xaH, , F n. �. // • S'„LSh °€1, y :,i h%zr "l A <y i,r • ••'s.,r� `GM •€€W y, r�s> s'„ M . 0". •y_y: ys v;>''s is•y -•4 £i% k ,:•-.,'yyrs E%s:'`'�`%`s,<'3'sg s .. _ fy �R rS.Y fF 5n <. $� 0'.d ��. z "z'� *€4 3�;. n: s,:.;y�x s - `ys £;stv S y s r 4 a` ` U(C) nit i. fir•' . y f'S f v�,s £ y si ..„...,,,,..:.„,,,..„,:tr..:,,,...„.....::,:,::,.::,.,..,,.:,...,,.:..„,:,...:,..,„::„,..,::„.::,.:,.:::.„.„„„;,:„,„,... f DA;!,::00.,,,),.!,:ogifitio*/ ,,,,4ftwo""''''' if r ,r"'"..*. .::0,; ,,,..:._, .:.0..;.:_.;-. . . ...... _-___-,_ _ 4. ..... ♦ G� • SL 1 3 u. . .. ------ !!, • • • II ;Y i i•—• • • %/ 0 J, yry (‘'it: )...,:TA1-1 . --"„ i...,.- ,41=:- ,,,444......T.,....... ,.....,. ,,, by E I .. c w«. w .,., ..,11/1 n. GGw: h6Mat }i '� �" k » . iu' 9 %.ay hri!rs'r :sAT/.Y. F-• •4";"*.e.'d—'elf 0 Mi.::: LIVING ROOM € • _'� BEDROOM °-s ro 2 1-BED .ems • i : • .1 UNIT TYPE C) DINING E: yytsz- • t Ilt • , % ♦tolr (/\ :: )."‘ • ; •.. ; C) I Q - sr • L it . t: 1 gi , ''. 1.• N.--,....,,___, irePE 3 by 1*-1 .•4' 3C13 s . YY x tat.N., �. i t'4 IA'' , t � : 0 :::. . • ..4 1 t .........r.. •, il ,, i ;w s �.. 's x 1•to -$314' Y°-7 3t4" b.. 0 Unit Type 3 1/4" '',,' l'-.0" >s AC DATE(MMIDDIYYYYI ''' CERTIFICATE OF LIABILITY INSURANCE 06/17/2023 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 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 Benson Young&Downs Ins CONTACT Carl Goveia 56 Howland Street 1H OON�Flay 487-0500 FAI NQ1(508)487-4135 PO Box 559 ApDRIFS4, carlgoveia@BYandD.com Provincetown MA 02657-0559 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Atlantic Casualty Insurance Co 42846 INSURED INSURER B Arbella Protection Ins Co �,41360 Bronov Enterprises Inc INSURER C:Travelers Indemnity of America 25666 72 Anchor Lane IN_S RERD: _ Cotuit MA 02635- 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. INSR TYPE OF INSURANCE IADDLISUBRI POLICY EFF POLICY EXP LIMITS LTR 'INsn wvn POLICY NUMBER IMM/DD/YYYYL IMM/DD/YYYY1 A X COMMERCIAL GENERAL LIABILITY ' 1M2050018110 07/02/2023 07/02/2024 EACH OCCURRENCE '$ 1,000,000 DAMAGE TORTED ]CLAIMS-MADE X OCCUR PREMISES( aocccurrrence) $ 100,000 MEDEXP_(Apy_oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- _ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ 1020102822 12/29/2022 12/29/2023 COMBINED t)INGLE LIMIT B AUTOMOBILE LIABILITY $ ANY AUTO BODILY INJURY(Per person) $ 500,000 ALL OWNED I X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ 1,000,000 X ' X NON-OWNED PROPERTY DAMAGE $ 250,000 ,, HIRED AUTOS AUTOS (Per accident)-.......—.. UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION '6HUB0G14209323 07/03/2023 07/03/2024 X A7ATIITF 1 :OTH- AND EMPLOYERS'LIABILITY /N 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Carpentry&Remodeling Operations and Cleaning Service. OFFICER OLGA BOCHKO IS EXEMPT FROM WORKERS COMPENSATION INSURANCE POLICY CERTIFICATE HOLDER CANCELLATION Al 008861 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 I/}j� SOUTH YARMOUTH MA 02664- AUTHORIZED REPRESENTATIVE • .. I Fax:(508)398-0836 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD THE COMMON .L-u -i OF lvIASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Regtstration rype Corporation F e tstra tt ry 182478 BRONOV ENTERPIRISE3 NC Expiration. 06/2 / 025 72 ANCHOR LANE C }T'UIT, MA 02635 Update Address end Return Card. THE M LTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual Lidt,e only before the HOME IMPROVES/ENT CONTRACTOR exofrotion cuts. if found return to, TYPE.Carooraton Office of COnflUtnef Affairs and ati$tnes3 Feiguistion Re014111ST1011 t 1000 Washington Street w Suite 710 18247 2 s5 Boston,MA 0 118 3ROW('r ENTERPRISES I EVGEN/Y BRONOV CO ' --�.. rt ` .MA ?< 3 tin erso ret ry � `�f d without signature 401 . Ccurfnonw of M Its Board of Building 4 *r t F .''s , ititilftlermisrds Dias f ,, lsr S-11 0 B %' it 1012 12t 2 EVGENIY BR NOv % ; "'', ' 72 ANCHOR 14ANE OTUIT MA 0,635 ', f ,r / 4 commissioner , to t: r-i Cts a, ,.. COMMERCIAL ONLY— BULDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: ZZA k002..Vt, c yaithoot* W Scope of Proposed Work: kro,00e Vif%cnryNc. LAA,,„),A r r t r` i k\ ort ,Z firn0.0c3 yr,44,S 0c61, \--typQ Date: 04/3O Z TZ,i Based on the scope of work described above, the applicant is required to obtain approval sign- offs from the following departments as checked-of below: Health Dept. —508-398-2231 ext. 12 1 Conservation —508- 398-2231 ext. 148 Water Dept. —99 Buck Island Road, 508-771-7921 Old Kings HWY. Hist. Comm. —508-398-22631 ext. 1292 Engineering Dept. —508-398-2231 ext. 1250 Fire Dept. —Kevin Huck/Matt Bearsej 96 Old Main Street, SY Note: Please call Fire Department for an appointment. 508-398-2212 Other Appropriate plans and/or application shall be provided to each departments checked-off above. Each of these regulatory authorities has their own requirements outside the jurisdiction of the Building Department. All applicable approvals shall be obtained prior to submitting a building permit application to the Building Dept. Thank you for your cooperation. Receipt Acknowledgement: Applicant's Signature Date/ Rev. March 2022 06 j/0/ZUz-3