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HomeMy WebLinkAboutBLDC-25-103 Yq SEP 16 20,5 1 446 Town of Yarmouth Building Department job '"'' 1146 Route 28 South Yarmouth,MA 02664 (;)&f,...--3_.) T i 508-398-2231 Ext.1261 Fax 508-398-0836 --� Building Permit Application for any Building other than a One-or Two-Family Dwelling L6C-c9,5(Q, (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: �7 .` 3 �� e rl/`�SECTIONLOCATI Zit/ yfime/ �P 4 �2� No.and Street City/Town ip 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 0 Repair 0 Alteration 0 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 Engineer' g P r feview required? l Yes 0 No 0 Brief D cri tion of Proppsed k: Q `p 6v O gDL'I�'f 64` 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) 0 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❑ Nightclub 0 A-3 ❑ A11 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 0 IB 0 IIA 0 IIB 0 IIIA 0 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: Public 0 Check if outside Flood Zone 0 Indicate municipal❑ 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: 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 ❑ 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 f Property O ner M % g( ��-e i L cL. .34; ,-f,, (4I. v-2 ©262Name(Print) No.and Street City/ Zip Prope Owner Contact Information: // soa7 quit - di- Telephone No.(business) Telephone No. (cell) e-mail address f applicable,the proowner hereby auth rizes: K.l � �erty c Name treet Address City/Town State Zip to apply for and act on the property owner's beh all matters relative to work authorized by this building permit application. SECTION 10:CONSTRU t'ION 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 Contract� r kcci1�..� ‘titkeAtie Company Na e V\� e-- S p 0 F'L.cs ' Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town tate Zi - - - - el()� k - t P Telephone No.(business) Telephone No.(cell) a-m ' P P 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 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Office Use Only 1.Building $ 7 el d Deposit Received$ Date 2.Electrical $ 3.Plumbing $ Permit Fee$ 4.Mechanical (HVAC) $ 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 application is ue and accurate to the best of my kno ledge an understanding. ��r S 77T7,4 *(j - Pleas'pr 4 • 0 ' le Telepho�f o. Date / 1� res l City/Town State Zip Email Addressl ikr. Municipal Inspector to fill out this section upon application ap royal: Name Date TOWN OF YARMOUTH 4 .r ' °' Office of the Building Commissioner t° qq 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. Work Address Is to be disposed of at the following location: 04, 144 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapt 11, §150A. @Vet ignature of Applicant Da Permit No. S,:„� The Commonwealth of Massachusetts _ Department of Industrial Accidents ram,- ,�. _ Office of Investigations s p� ); Lafayette City Center *a 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/Organizati 1►/I ividu * A eipi Address: 724 1 Pg 4 ��-' s a. City/State/Zip: 9. Ci1- 19266 Phone #: S o 7 7 7‘‘'. 7 . 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. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 10 Remodeling ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9. 111 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 12.0 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. 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. 1 am an employer that is providing workers'compens ion insurance,far my employees. Below is the policy and job site information. Insurance Company Name: — ai l Policy#or Self-ins. Lic. #: 6S-6 ira ion Date: �� l ot �c> Job Site Address: 2-- 'Z at i : flt4a2 _ Attach a copy of the workers' compensation policy declaration p e(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 verificatiati• I do hereby certify er th pains a/d penalties of perj—. '� he information provided above is true and correct. Signature: , Date: ( /�i �( Phone#: 6 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 31:City/Town Clerk 4.0 Electrical Inspector 51=.IPlumbing Inspector 6.0Other Contact Person: Phone#: e. ti) N e> , N , to 6. -...., . „ as 1c1.— E IV it; so st)'" els tl in c o U 3 0 D ''iti a"5:.•,-' .. 'r-i ..__ . IT,▪ o EC"II •-, +a 0 004 c W 119 4) <CI X I0 o Ca ao 0 0 .'.... e) . , ACCORD'® CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYY() THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.2THIS 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 INSURANCE AGENCY INC PHONE Kimberly Fitzgerald (508) FAX 1ALC,LI�Ext): 775-4559 (A/c N J_ E-MAILkim ADDRESS: m loveletteins.co 396 MAIN ST C� EST YARMOUTH INSURER(S)AFFORDING COVERAGE NAIL k WMA 02673 INSURED --- - INSURER A: HARTFORD UNDERWRITERS INS CO 30104 HEALY BROTHERS CONSTRUCTION INC INSURER INSURER c: __ ---- 72 OLD MAIN ST INSURER D SOUTH YARMOUTH INSURERS: MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 1143261 NUM THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDS NAMED RVISION ABOVE B OR.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 _LTR TYPE OF INSURANCE !NWWVD POLICY NUMBER POLICY EFF POLICY EXP -- COMMERCIAL GENERAL LIABILITY (MM/DD/YYYY) (MM/DD/YYYY) LIMITS 1 CLAIMS-MADE I OCCUR EACH OCCURRENCE $ DAMAGE—TC)R€NTED PREMISES(Ea occurrence) $ N/A MED EXP(Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL$ADV INJURY $ -- POLICY LJ JECOT- I I L,OC GENERAL AGGREGATE $ OTHER PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY $ ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS N/A HIRED NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE — - - (Per accident) $ UMBRELLA LIAR $ OCCUR EXCESS LIAR CLAfMS-MADE N/A EACH OCCURRENCE $ DED RETENTION$ i AGGREGATE $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY OTH- ANWROPRIETOWPARTNER/EXECUTIVE Y/N STATUTE ER A OFFICER/MEMBER EXCLUDED' IN/AI N/A N/A 6S60UBOW65672425 E.L.EACH ACCIDENT $ 100,000 If in NH) 08/19/2025 08/19/2026 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A IDESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensaton 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 none ACCORDANCE WITH THE POLICY PROVISIONS. none AUTHORIZED REPRESENTATIVE S Yarmouth MA 02664 F w4 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved. / I ACORL�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �� 08/11/2025 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 pollcy(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 NAME: — -- PHONE 396 Main St JAC No_EXt): (508)775 4559 I FAX No): West Yamouth,MA 02673 E-MAIL marshall@loveletteins.com ADDRESS: @loveletteins.com INSURER(S)AFFORDING COVERAGE NAIL# ---- _ INSURER Nautilus Insurance CO 17370J INSURED Healy Brothers Construction, Inc. ---INSURER B 72 Old Main Street South Yarmouth,MA 02664 INSURER C: 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 T LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY A t/1 COMMERCIAL GENERAL LIABILITY ) (MMIDDlYYYY) LIMITS NN1791710 01/09/2025 01/09/2026 EACH OCCURRENCE $ 1,000,000 DAMAGE !TENTED CLAIMS-MADE 11;OCCUR PREMISESO(Ea ccu ante) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY PRO GENERAL AGGREGATE $ 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: --. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $_ OWNED BODILY INJURY(Per person) $ SCHEDULED AUTOS ONLY AUTOSBODILY INJURY(Per accident) $HIRED NON-OWNED _ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) _ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE $ AGGREGATE $ DEO ''RETENTION$ --- -- - WORKERS COMPENSATION $ PER OT AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED7 I I N/A E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below -- -- E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A2.07"eZe - 0 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD I • i I OI�� 441-jf,...._t_5 • I t IP— c,„>, __________.. . . .. . F. ,..... . • . CD 4) • Fli, : . . . i _• _ , _ -__ ,_. • e '47 ,,,, -...! ...._ .._...... . . ... . . .._.... .. . . F- -.............__........ . .�G , ,, ....-v .1-N , . , . _,___________________ ". 1 iii. .. ... .. ... . , 1 „......„ i .,‘ \ ___ _ . . ) , q • 0 i + 1 . -7---" ,...._...,::: , --; .‹. -L. _........ ..- ---, - • `..Posolli r , ... _., V ....__ .),.., i i -.