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HomeMy WebLinkAboutBLDC-25-143 g Y Town of Yarmouth Building Department �.,. 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 Dwelling �+I 1Y. —: 5—)1 3 (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCAT N k /( Mote 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 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 Engineering Peer Review required? Yes 0 No 0 Brief Descriptiq of Proposed. ork: AIS7✓1- 7 t ' 'c• w 1- ti CID"/Z i SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING REN ATTN,ADD I N,1 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 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 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 ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis osal Site 0 Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be P 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 and Address of Property Owner pC I0 NO 0 k VitA-4 r vV,'-fr Mfg Name(Print) No.and Street City/Town Zip Property Owner Contact Information: °noir SOcic - -Ill() Sob, 2 43-t31/ bt�+Mo►i�,C 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❑. 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 14116k ok_e. a liA420,tv_\41/4 Company Name Name of P5rspn Responsibl ion License No. 9,qype if Applicable `20201of P .4 S e (2- o 4( 4/ Q 46L� Street Address Ci Town Stat Zip _ - ? -77�3 V---1) he4 i Telephone No.(business) Telephone No.(cell) e-mail ad4tess 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 $ � V Deposit Received$ Date 2.Electrical $ 3.Plumbing $ Permit Fee$ 4.Mechanical (HVAC) $ 5.Mechanical (Other) $ Net Due$ 6.Total Cost $ s -r 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. Please print and sign name Title Telephone No. Date 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. Other (if applicable) 'ZN. The Commonwealth of Massachusetts Department of Industrial Accidents 9 Office of Investigations a =1 Lafayette City Center 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Pleas 'tit Legibly Name(Busines anizatio d dual):,,t�,� Address: R B .....4 , . City/State/Zip: pt 4- o6 1—f Phone#: 0? 7G t 7(z Are you an employer?Check the appropriate box: Type of project(required): 1I 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 listed on the attached sheet. 7. ❑Remodeling 2.❑I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' P tY• 9. ❑Building addition [No workers'comp.insurance comp.insurance.t 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 11.0 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' 13.0 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �L ll L Insurance Company Name: /+L 4 P/j� d{��-tom i /\/ U✓-7W9\�Z tt f{2`TtJlrR • Policy#or Self-ins.Lice.#: (e S 6 D U4 lJ��V J V/o(i Expiration Date:. ?`161—�z 2,, 'r Job Site Address: `/`i 44' O City/State/Zip: (,(J�� ��2/t01/�L 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 vu:fication. I do hereby certify ,er he pains„'pen' .- -i f perjury that the information provided above is true and correct Signature: a ��' Date: S J-ee___ 2,025` Phone 2 • .1ii, ,76 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 50Plumbing Inspector 6.00ther Contact Person: Phone#: �g A ,, TOWN OF YARMOUTH. Office of the Building Commissioner t �° � y, 4South Yarmouth, VIA 02664 b �- �� 11 6 Route 28, .,�tyco .� RAro; s 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. rc, Work Address Is to be disposed of at the following location: Vff12A9-1/1/ (4114-' C"-1 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter , 150A. Sig ature of Applicant Date Permit No. ® A�0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/10/2025 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 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 Kimberly Fitzgerald erald NAME: MARSHALL K LOVELETTE INSURANCE AGENCY INC (acNro Extr (508)775-4559 FAX No): E-MAIL ADDRESS: kim goveletteins.com 396 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# WEST YARMOUTH MA 02673 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B HEALY BROTHERS CONSTRUCTION INC INSURER C: INSURER D: 72 OLD MAIN ST INSURER E: _ SOUTH YARMOUTI-I MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 1178967 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 ADDL SUBR POLICY EFF I POLICY EXP LIMITS LTR INSD WVD, POLICY NUMBER (MM/DDIYYYY)I(MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE RENED CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY `IECT LOC PRODUCTS-COMP/OPAGG $ 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$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ER YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED9 N/A N/A N/A 6S60UB0W65672425 08/19/2025 08/19/2026 - --- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensalion 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 El Mariachi Mexican Restaurant ACCORDANCE WITH THE POLICY PROVISIONS. 416 MA-28 AUTHORIZED REPRESENTATIVE ( West Yarmouth MA 02673 ro Daniel M.Cro 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 DATE(MMIDD/YYYY) AC RD® CERTIFICATE OF LIABILITY INSURANCE 12/10/2025 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 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.Extl: (508)775-4559 (A/C,No): EMAIL marshall@loveletteins.com West Yamouth,MA 02673 ADDRESS: 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR�. INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A COMMERCIAL GENERAL LIABILITY NN1791710 01/09/2025 01/09/2026 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ti OCCUR DAMAGE TO RENTED l OO,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE_IMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY I'RO 1,000,000 JECT LOC PRODUCTS-COMP/OP AGG $ 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 LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RE1 ENTION$ _ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPE.RATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may he 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 El Mariachi Mexican Restaurant ACCORDANCE WITH THE POLICY PROVISIONS. 416 MA-28 West Yarmouth,MA 02673 AUTHORIZED REPRESENTATIVE I j `in°C ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Gonrrrtonwealti*of Massachusetts Division of Occupational Licensure • Board of Building Regj ulations and Standards i Cons ifton Lgc'f t'vlsoi n/1 C3-060855 x - Aires:11/22/2026 MICHAEL A FS£ALY 72 OLD MAIFkST SOUTH YARMOUTH MA 02664 ' L>� Commissioner t , N 4. (6. gN .__ . 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