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Home My WebLink AboutBLDC-25-7 application ��Y" Town of Yarmouth Building Department r3'o y 1146 Route 28 South Yarmouth,MA 02664 508-398-2231 Ext.1261 Fax 508-398-0836 Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number:8 L'ADC'—a5---Date Applied: Building Official: �S t SECTION.:LOCATION 4,p2q7 & a4r Odb No..92eet CitygQwn Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot# �2 SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repai Alteration ❑ 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 N2>SK Is an Independent Structural Engineering Peer Review required? , Yes 0 i _-/ Brief Des ipt' n of P posed Work: / rP �� 4� 'e /'/Dy 1/l�l��/��41/l7� ,��Q a 4'4 n/ I ,'i55o4 „wife .l e_� �Ar�r,#/obi. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENO RDEACDEIlL1VOM D CHANGE IN USE OR OCCUPANCY r Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 JAN 21 2025 Existing Use Group(s): Proposed Use Group(s):- SECTION 4:BUILDING HEIGHT AND AREA BUILDING_DLPARTMLNT Existing 8y rroposea 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 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5❑ I: Institutional I-I 0 I-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-ID R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2❑ U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB0 IIAO IIB 0 IIIACI IIIBD IV VA 0 VB 0 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 D Private 0 or identify Zone: or on-site system 0 required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: 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 0 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: Design Occupant Load per Floor and Assembly space: • SECTION 9: PROPERTY OWNER AUTHORIZATION Name a d Address o Prop rty Owner � 1 ciatIO , i c ,pj �,7 /0"/.,/il ./%6, /1,19 c.".?6,? . Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 014/1PV 6'�_ -'3o8,' �ii '-48'.a�-0/3c Title Telephone No.(business) Telephone No. (cell) e- ail address If secible,the property caner 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 hey 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 General Contractor Company Nam Na , ��ic /20:1/eh* Cam- $ ggg4f7 Nally of Person)~2�ns e r onstr e /�/� c No. and Type if Applic ble ��i0 �7 4 ? K/ Street Address City/Town Stale Zip . .°7 .77,c-- 9 7 -_wir1-7r i lEe e eak/P,f : Gv1P Telephone No.(business) Telephone No.(cell) e-mail 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 i suance of the building permit. Is a signed Affidavit submitted with this application? Yes No 0 SECTION 12:CONSTRUCTION COSTS AND PERMI l 'h,E Item Estimated Costs:(Labor and Materials) Office Use Only 1.Building $ .. P Ad .� Deposit Received$ (J o _7 2611 Date 3)Z 1)Z5 2.Electrical $ l� 3.Plumbing $ Permit Fee$ `J V 4.Mechanical (HVAC) $ `G Q 5.Mechanical (Other) $ Net Due$ 6.Total Cost $ 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 app" on is true and accurate to4he best of my owledge and understand" g. '4/1 .0 Plea e pr' t and sign n e / ' Title Telephone No. Date/ y/ Street Address // i Cty/ty//�FToWwir/ tate tp y� Email Address Municipal Inspector to fill out this section upon application approval: Name Date JO Ln ( rz h1rrJ'. ,O,ri • 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) Tel-ephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Tel-ephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date - Name(Registrant) Tel-ephone 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. The Commonwealth of Massachusetts Department of Industrial Accidents • _ __ Office of Investigations ___.— = Lafayette City Center =ty 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): gtoh I ' s Address: 2 7 41 ya-pm t.av /l City/State/Zip: G�.ww C]Z(o a ( Phone #: 5-b 3' 7 1 s`" 3 8 3 Are you an employer? heck the appropriate box: Type of project(required): 1.E lam a employer with Le of 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 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 workingfor me in anycapacity. employees and have workers' 9. E Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 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' 13.0 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. L n _ Insurance Company Name: F e- ` 4.1-- .4-KS . Policy#or Self-ins. Lic. #: ,,/6J /0(0 `L30 7 Expiration Date: j Z Z— 1 -� ZJ Job Site Address: 2_? 7 I-C'- 't g w• )(A.P1,4vt4,uftN-- City/State/Zip: 0 26 73 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 verification. I do hereby certify under the pains and penalties erjury that the information provided above is true and correct. Signatur 0 L_ 1-7, , f 1' T Date: - 2-1 —Z✓--- Phone#: 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 3OCity/Town Clerk 4.❑Electrical Inspector 5ilumbing Inspector 6.0Other Contact Person: Phone #: ri Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons iontJS��p rvisor CS-098997 ,Y' ,, spires: 11/19/2025 MICHAEL K ttOBICHAUD 47 MARBLE OAD a BARNSTABL MA 0263 2 , Commissioner AMR DATE(MM/DD/YYYY) AM CERTIFICATE OF LIABILITY INSURANCE 10/30/2024 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). (.UN 1A(.1 PRODUCER NAME: CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY PHONE FAX _ HOME OFFICE: P.O. BOX 328 (A/C,No,Ext):888-333-4949 (A/C,No):507-446-4664 OWATONNA, MN 55060 E-MAIL ADDRESS:CLIENTCONTACTCENTER@FEDINS.COM INSURERS AFFORDING COVERAGE NAIC# INSURER A:FEDERATED RESERVE INSURANCE COMPANY 16024 INSURED INSURER B: ROBIES REFRIGERATION INC INSURER C: 279 YARMOUTH RD - HYANNIS,MA 02601-2038 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:0 REVISION NUMBER:0 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. INSRL TYPE OF INSURANCE ,INSRL SYU(BAR POUCY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDDIYYYV) (MMIDDIYWY) X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES $100,000 (Ea occurrence) MED EXP(My one person) EXCLUDED A N N 6120004 12/21/2024 12/21/2025 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $2,000,000 X POLICY CT LOC PRODUCTS&COMP/OP ACC $2,000,000 OTHER: YYYY COMBINED SINGLE UMIT AUTOMOBILE LIABILITY accident) $1,000,000 CO X ANY AUTO BODILY INJURY(Per Person) A OWNED AUTOS ONLY SCHEDULED OS N N 6120003 12/21/2024 12/21/2025 BODILY INJURY(Per Accident) HIRED AUTOS OWNLY NON-ONED PROPERTY DAMAGE AUTOS WONLY (Per Accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $3,000,000 A EXCESS LIAB CLAIMS-MADE N N 6120006 12/21/2024 12/21/2025 AGGREGATE $3,000,000 DED RETENTION WORKERS COMPENSATION X PER STATUTE OTHER AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $500,000 A OFFICER/MEMBER EXCLUDED? N/A N 6062307 12/21/2024 12/21/2025 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE POLICY UMIT $500,000 1 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) THIS COPY IS NOT TO BE REPRODUCED FOR ISSUANCE OF CERTIFICATES. CERTIFICATE HOLDER CANCELLATION A CERTIFICATE HAS BEEN FILED WITH EACH OF YOUR 0 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED CERTIFICATE HOLDERS. BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1 r \Ai 1......„ "z''< 4,‘,,, • - (ki: l'..... til, , ,&,, ,,,,,‘ h *2.4'\\'' 4 h 1 .. i •Cti: % . 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