HomeMy WebLinkAboutBLDC-25-39- o, Town of Yarmouth Building Department
F '''' 1146 Route 28 South Yarmouth,MA 02664
•„ 40 % 508-398-2231 Ext.1261 Fax 508-398-0836
Building Permit Application for any Building other than a One-or Two-Family Dwelling
abl.-tea 5- 39 (This Section For Official Use Only)
Building Permit Number: (Date Applied: Building Official:
ASS R.N e..'oL : Coy(ZSP_ SECTION 1:LOCATION
10:8e j 7 c,a YAs. Mo 4114 as66v
o.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 v If New Construction check here 0 or check all that apply in the two rows below
Existing Building fa. Repair 0 Alteration 61. 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 J No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No XI
Brief Description of Proposed Work: Fx r x IS;.NC .' E( ►1>=7'1.146 EL I i✓ 6
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) D _y
Existing Use Group(s): Proposed Use Group(s': R EC
SECTION 4:BUILDING HEIGHT AND AREA
Existir g MAR 1 brcarif
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.) BUILDING DEPARTMENT
Ry
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 ❑ F2 0 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 D IBO IIA 0 IIB 0 IIIAD IIIB 0 IV 0 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:
pp y' A trench will not be Licensed Disposal Site 0
Public 0 Check if outside Flood Zone 0 Indicate municipal❑ required 0 or trench or specify:
Private❑ or identify Zone: or on-site system❑ 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❑ 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 and Address of Property Owner
3A.SS EoiASE Hi g&v,it' SbV4l} Ytv2w10 .-H'( (
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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 0.
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
C\- .uJF esuit_4\rr2s
Company N. rrie
CAI-SPik)NF C S 0 cz, ag6
Name of Person Responsible for Construction License No. and Type if Ap licable
3 A LF;2E i F 161 L I • )Ntk . ii-i b ENNi S I fI N d L 6 0
Street Address City/Town State Zip
•
611 -$57- 31tld -pjk,rlE c�L� ;ZS Woo
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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes CI No CI
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Office Use Only
1.Building $
Deposit Received$ Date
2.Electrical $
3.Plumbing $ Permit Fee$
4.Mechanical (HVAC) $
5.Mechanical (Other) $ Net Due$
6.Total Cost $ j�0/00 0 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 m>l5nowledge and understanding.
('1 VJIO, h'EJ 4)A,,F. 14 fe�""'' 6I7 _$dr 3q`/ 3-19
Please print and sign name A Title Telephone No. ate
14J-iet:-/) d 740 if )4 _sout o yoni mfl. 63 W d t�A►nr>;'8 Lb R S &VAAa•ktm
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 req lire 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
Registration Number
Name(Registrant) Telephone No. e-mail address
Discipline Expiration Date
Street Address City/Town State Zip
Please follow this link for construction control forms to be used by Registered Design Professionals.
Ya TOWN OF YARMOUTH
Office of the Building Commissioner
1146 Route 28, South Yarmouth, MA 02664
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. 1--1,;J ,4Ai R 1�
Work Address
Is to be disposed of at the following location:'RAalr(F ( S)4*a tyt,
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, §150A.
,, P CA, 3 V\ a (9'
Signature of Applicant Date
Permit No.
Commonwer:ltti cif Mrtasschusittit Construction Supervisor
11 Division of Occupational LlcsnwNre Unrestricted-Buildings of any use group which contain less than
Board of Building Re uiatlona and Standards 35,000 cubic feet(991 cubic meters)of enclosed space.
rla Ix� ivlsor
cp
eS-0$8280 lres.08/16t20!
CHRISTOPHER PAINE 2 ate,
31 ALFRED METCALF DRIVE _ it
SOUTH DEMOMA 02660 ;r
dk ,,0
4.1,v,tA 1 Failure to possess a current edition of the Massachusetts State
r� y�/
Building Code is cause for revocation of this license.
CommissioCommissionery s1-etk.d4t.. • Contact OPSI:(617)727-3200 or visit www.mass.govldplIopsi
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:Individual Office of Consumer Affairs and Business Regulation
Registration Expiration 1000 Washington Street -Suite 710
139223 08/24/2025 Boston,MA 02118
CHRISTOPHER PAINE
CHRISTOPHER PAINE -
31 ALFRED METCALF -
S.DENNIS, MA 02660 �P�
Undersecretary Not valid without signature
•
. The Commonwealth of Massachusetts
Department of Industrial Accidents
l�� Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
-,a:5
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): (Iira f 7/.J/WF SU I ► (i-Z 5
Address: At rid Ilk k ALI- K.
City/State/Zip: &?' I>~ !J P& v I$ NA o,3.66° Phone #:b 17 g)'1 y Li
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. 0 I am a sole proprietor or partner- listed on the attached sheet. 7. [l Remodeling
ship and have no employees These sub-contractors have 8 ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.+
required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*My 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 verification.
I do hereby c tO7 under the pq• s and penalties of perjury that the information provided above is true and correct.
Signature: ti cen'` Date:.3'� I1^ a 0 -j
Phone#: eV 1 - l - 3 LI LI
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 3❑City/Town Clerk 4.0 Electrical Inspector 5.0Plumbing
Inspector 6.❑Other
Contact Person: Phone#:
i��IS+INS'
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