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HomeMy WebLinkAboutBLDC-24-125 #7 �J asg"" . Town of Yarmouth Building Department �.,,a o y 1146 Route 28 South Yarmouth,MA 02664 ' ...,,`�"�',..•4 508-398-2231 Ext.1261 Fax 508-398-0836 Building Permit Application for any Building other than a One-or Two-Family lling 3 L f\C_Zy I S (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: 1' 7� g SECTION 1:LOCATION 147 g N 5- /Lt-c_2,p' 5 q vk es) /2-6 b /-- ',...aL 12-t,�,., r No.and Street City/Town ! Zip Code Name of Building(if applicable)' Assessors Map# Block#and/or Lot# SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building( Repair 0 Alteration Itr Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 0 Brief Description of Proposed Work: RGrcp.sr i i>vod.. 4A..:d rst -j-'oa) I ZL&/ d S V -BV 6.1.�C-- LaD 4-tiv.4.,...4? { i" S 'v' !I J-u1 44444-.2."_, t-t2 L,, SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) CI Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2❑ H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB 0 IIA0 IIBO IIIAO IIIBC IV 0 VA 0 VBC SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0 required 0 or trench or specify: Private 0 or identify Zone: or on-site system 0 permit is enclosed 0 Railroad right-of-way: 1 Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No❑ Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain a Sprinkler System? Special Stipulations: ' RECEIVED Design Occupant Load per Floor and Assembly space: SEP 19 2024 BUILDING DEPARTMENT By. __ SECTION 9: PROPERTY OWNER AUTHORIZATION Na2e!dnd A ress of Prplgerty O,:'e J ' I n /�'1i�L ` T,_], VV Se-veil � )`pVj 1�J,l/Y�1( Name(Print) No.and Street City/Town Zip`V ty Pro eO er Ctact Information: •V"f0/I L Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control,then check here D. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 Gener atvContracto N V\ •evstA. Company Namel ,1ik.LA►h V4 ef/j. Name of rietton Responsible for Co t do License No. and Type if Applicable Street Ad ess ` City/Town State Zip ‘Or� )7(� ty/ pu h�e S41 ka— AS Cv''� Telephone No.(business) Telephone No.(cell) / -�1 1' H address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes D No D SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Office Use Only 1.Building $ .1/rip Deposit Received$ Date 2.Electrical ✓ $ - 3.Plumbing • $ Permit Fee$ 4.Mechanical (HVAC) $ 5.Mechanical (Other) $ Net Due$ 6.Total Cost $ 11 617 Make check payable to Town of Yarmouth SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Oc>E I j S-4fr 737 9 iY Please print and sign name Title �'elephone No. Date 35 S�v e-du-Gc_1�`Ltc:::44.ux tt el— 4:="1.b -.J lsyw'c6 t'v U le j e&9•.�4i*r1.csa...Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing(include local connections) 9 Gas(Natural,Propane,Medical or other) 10 Surveyed Site Plan(Utilities,Wetland,etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. g Ya' TOWN OF YARMOUTH '; :- : o, Office of the BuildingCommissioner q 1146 Route 28, South Yarmouth, MA 02664 s.b NCO AY 508-398-2231 ext. 1260 Fax 508-398-0836 DEMOLITION DEBRIS DISPOSAL APPLICATION Pursuant to M.G.L. c.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., 7 g l jJ I2-c-L a F = A 12 iu ouibe Work Address Is to bedisposed of at the following location: 7 /110114.1 Said disposal site shall b c ed solid waste facility as defined by M.G.L. Chapter 111, §150A. _61 Signature of pplicant D to Permit No. The Commonwealth of Massachusetts '' Department of Industrial Accidents Office of Investigations ' 9---gre*.e _a s (s Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 yV/ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Ptle se Print Legibly l. Name (Business/Organiz .cz 1t1nd ' 1 ividual): ( () ,t v N Address: 7,2_ D m def t„.`. City/State/Zip: 4 ivbe 1l Phone #: / 76 . ,(6 Are you an employer? Check the appropriate box: Type of project(required): 1.54i am a employer with �y 4. ❑ I am a general contractor and I ` * have hired the sub-contractors 6. ❑New construction employees (full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.P1 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage v - ation. I do hereby certif er th ains an penal of perjury that the information provided above is true and orrect. Signature: Date: 1 7 4/24 Phone#: STh 2 77> 5 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.DOther Contact Person: Phone#: Commonwealth ot Massachusetts Division of OccUpatiOnal Licensure W Board of Building Rilationsend Standards Const ionritkigvisor -14 C56060856 ires41/2 024 MICHAEL A ,`72 OLD MAIc' L a SOUTH YAR1015) '"+,• SfY3 ket 4tV • soaggissich. far. tve02-Aus::-. 2.0 • , . -. 4., 4-1 • r • • • ( • • • • • Aco E! CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �.� 09/19/2024 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 CONTACT Marshall Lovelette MARSHALL K LOVELETTE INSURANCE AGENCY INC PHONE (508 775 4559 FAx (A/C.No.Extl: ) (A/C,No): E-MADDRESS: marshal)@loveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WEST YARMOUTH MA 02673 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: HEALY BROTHERS CONSTRUCTION INC INSURER C: INSURER D: 72 OLD MAIN ST INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 1046879 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. INSRLTR ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ I $ WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY ANYPROPRIETORWARTNER/EXA OF ICER/MEMB REXCLUDED?ECUTIVE N/A N/A N/A 6S60UB0W65672424 08/19/2024 08/19/2025 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ N/A I � DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 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 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cro I y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AcoR0® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/19/2024 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 CONTACT Marshall K.Lovelette Marshall K Lovelette Insurance Agency Inc PHONE FAX 396 Main St (A/C.No.Ext): (508)775-4559 (A/C,No): West Yamouth,MA 02673 ADDRESS: marshall@loveletteins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Nautilus Insurance Co 17370J INSURED Healy Brothers Construction,Inc. INSURER B: 72 Old Main Street INSURER C: South Yarmouth,MA 02664 INSURER D: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER ,(MM/DD/YYYY) (MM/DD/YYYY) LIMITS A ✓ COMMERCIAL GENERAL LIABILITY NN1637497 01/09/2024 01/09/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE I AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 Rt 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE /e.240./ eZa - ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NOTES w )J \k\`\ CV\- it\ S R-k �F stsv - � wt,bi ...,000/70 T ./,,,,t1 v,, Asv-12()_ uo-fA-(/( vi t.-tct3 = Qx6 ________ C.- 16-c. i Vo 4 771 e ,.c;113 14) 711 ku• a t k�� R