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HomeMy WebLinkAboutBLDC-25-112 #.1924.6 5-et) OCT 0 2 2C25 4 o Town of Yarmouth Building Department 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 mil— (i (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION P,P- #. Y kv, p,fk o?e h ca.,ro Th,a...—cat' 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❑ RepattS 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 Notle Is an Independent Structural Engineerin Peer Review required? Yes 0 No'� Brief Description /of Proposed� Work: OkC_n kn(,e, i n 1(111yA t l4Csf be C.4e dim € -+.."�� 7 e 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) 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❑ 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-1❑ R-2❑ R-3 0 R-4❑ 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 IBD IIAD IIB 0 IIIA 0 IIIB0 IV VAO VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Licensed Dis osal Site 0 Public 0 Check if outside Flood Zone 0 Indicate municipal❑ 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❑ 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 Name(Print) No.and Street City/Town Zip keEoperty Owner Contact Information: "Wy 210 " l - - Sb$ -' op-� o.vriyy. Z.•,hfk9 &,,13 Title Telephone No.(business) Telephone No. (ce I) 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 O. 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 i h#' ri-Avngew.f hc, Company Name R+i SS l z 1 Ne ,2 �-�-- )1 to 12-7 U Name of Person Responsible for Construction License No. and Type if Applicable 3t't MiI,w,15+- gre, a'te" ' 31 Street Address City/Town State Zip 9o8 CO sbs.� —� - Ru�w+�94.5 �I-i,� .`"', Telephone No.(business) Telephone No.(cell) e-maTh cttidress 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? No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FE Item Estimated Costs:(Labor and Materials) Office Use Only 1.Buildingp_r-vovit)4/1„pryyr Deposit Received$ Date 2.Electrical $ 3.Plumbing $ Permit Fee$ 4.Mechanical (HVAC) $ 5.Mechanical (Other) $ Net Due$ 6.Total Cost $ )0 p�� 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. awn. Ih M"drle _WO _2 4 " 0/2_ Pl se rint and sign name h Title Telephone No. Date f u+kr14tev W./ov-n0tf /1' A 6 ,1"7_3 nney1$hevGoicr-vv,cte. Street Address City/Town State Zip Email AddreskT")-f-1'I,7.+^\ Municipal Inspector to fill out this section upon application approval: Name Date '� PI L—f/f9f\1cpC ' E,D i9/( . C0Al IP SECTION Si CONSTRUCTION SERVICES 1.1 Construction Supertisor License(CSL) US 1 t b 1 Z2 I f f J1? 2_ 1 i�111-YI T A L License Number Expiration Date Name of 'S older 11 IV')ain List CSL Type(see below) Li AYH:SHE)�i�el ---- - -- -- - ------ T D SeriPiiefl R U Uotosirioted aloildioli s ap to 660 oil.rt.) L 3 e- ,- , A 0 L io 3 I R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel hurling Appliances S gib b 5'0.570 k 4"tc,m cis e,- I Insulation Telephone Email address .s:-►.A.,) (1411 D Demolition 5.2 Registered Home Improvement Contractor(HIC) -1-1,,, tom'Lc- Pi' t 1e-ni 1h G. WYni+l'€i../ CvLc,11..Q..\ HIC Registration Number Expi lion ate Company Name or HIC Registrant Name Nti: tteel filt}ali Ake wc.4T (YU73 Coe 0q02v?T City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application, Failure to provide this affidavit will result hi the denial of th Issuance of the building permit: Signed Affidavit Attached? Yes No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Q`iy5 f14.,rs� l;§§Own c of to§11�eFi ivefllyt bees 4Illht s i s '.1 wt � s L1c. m�..l ---ee 1 c,•.._- to act uu thy lialI;in all ti peg relative to Whfk diltilhflied by thi§building1€applieati8n: AiadA, ' —a,'11 _.-..." Ot.',IP _ ( / Print • , er's Name(Electronic S ,1144iii Date SECTION 7b1 ® ' NEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in t�uis application is true and accurate to the best of my knowledge and understanding. ----Z". I 0 I/2,'S" nni ners �r Aut�naec A cut's anima eclmn�c i ❑ature 9 t Mi 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths }1 ~ e of.hea tiii s vg em--- umber oof decks'poorctles 1• `tfiliigl lrstige>:§aliqfs<f8ai,1i s+"1liffle bs§l+h§tiHlissl ff"TOR!Pft3is Et Fil§r .. l•.1,� 1 -new your license, license renewal becomes available 60-days p ..ation date. Licenses cannot be renewed earlier than this date. 4 4MER. RUSSELL T License Status Expiration A Number CS-1 1 o i 2 7 Active 11/19/2026 visor .ii 0t see your fiterise? Click here to search for Et, tiv's'. L .:, .gyp: .......:---,..w...n ...+.o.......,......-..r...w•»—,......ie--,=...w.,.....,..�,,,.-,we,.. or a New License - ,..----"" a lie CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) i g!1§M0i§ fi141§ §Elifil€i§AME I§ ISSUE® A§ A MAfEI3 ®E iNE®NMA1i®N ONLY AN® §®NEER§ NO 141614f§ UPON NE §E141IEI6 f§ NOLOER: fil,ii§ 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§W111i96ATION II§WAIVED:§He(get to the t FRI§§Re EBnttitien§et thB :Bile €sit7iR_pBheig§RISy FBEHIFe§R PRBBF§PPIPPI: A§t§tWm9nt en H IRO tliiiss het tell*Witt t§thH t11rthlt110 hel§0r Ht He et ir>i-� ,� n tillir win rou outhheast LLC bba RO ersG ray •'_: FAX - - --- t � l� ltheast LLC�ba Ro�ersGra dkiCrl®.Extt`3@8 74B'3`3(} 'kis,Noi: c.:�•508-746-3311 rAn- Nn Hyannis MA02601 ADDRESS: INSURERS)AFFORDING COVERAGE NM* License#:PC-514062 INSURER A:Selective Insurance Co of Sout 19259 tNSUR€e Tr+a€AIL=4 INSURER a(_O fItyr Ind !y Ineurenoe CO 33618 Thr(i!O Piller0 Inc 4 Butler Ave lNSume c i Associated Ern I re Insurance - 11104 West Yarmouth MA 02673 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:222390888 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 SE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED NY THE POLICIES DESCRISED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES:LIMITS SHOWN MAY HAVE SEEN REDUCED SY PAID CLAIMS: _ MS -[HHCBUIlRT- POLICY @Pr POLICY EXP r LlMrrs LTR TYPE OF� W MI INSD VD POLICY NUMBER (MDD/YYYY) IMM/DD/YYYY! A X COMMERCIAL GEERALLIA&UTY S 2572439 11/4/2024 11/4/2025 EACH OCCURRENCE $1,000,000 � DAMAGE TO RENTED !,v,J-,VfA°E N-'v I'R€ML,ES(ES "T"ta1 5 soo,Deoo — klEBHPMIMEN) — i# ;'s; --------------- (MN%A88R€FAT€LIMIT AwlSS POW ceN€NAL AO6MSOAT€ .---$4,0_00_t100__ X POUCY Eei LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: $ B AUTOMOBILE LIABILITY COM 5926735 03 9/13/2025 9/13/2026 COMBINED SINGLE OMIT $1,000,000 (Ea accident) ANY AUTO PBBILY!NARY(Psi rims) ; -- OWN§ONLY X U6g® ®®OILY INJURY(Psi aot) ; - x N . x tO WNNtO pp�( AUfos ONLY AUtO ONLY (PEUr ecci6E6O $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ — Via- 1. as�. .1- �r tit BH 3d'c8ii -fb If�� � f B�$ � fibf8 8 ANYPROPRIETOR/PARTNER/EXECUTIVEri N/A E.L EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? - (Mandatory In NH) EL DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E-L-DISEASE-POLICY LIMIT $1,000,000 1 1 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 South Yarmouth MA 02664-4492 AUT AUT _O REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents h Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ',4 l www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): in��c., Pt 11 e,,, �b L. Address: Li 13-LA 1 Z✓ }) Ur_ L.J C MPv-v)-- Pr(..,,I.h YY1 0? .V?) City/State/Zip: Phone #: c--0 Ec 0 - -y - Are you an employer? Check the appropriate box: Type of project(required): i7 'I am a employer with 3' 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 ro rietor or artner- listed on the attached sheet. 7,Remodeling Alp and have h@ einp1oyee§ Thew§tilm,eohtfaelog §: ® Ae iolitioll woi4ing €uf HIE in ally bil[3dEit : eiiipleyEe§ diiti have Wd f§' 9. E building addition [No workers' comp. insurance comp. insurance.t `"" " required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.El 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 ❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 15 Other Q.t;p Y +rG i�-�, comp. insurance required.] t...)°N4e.'poly...0)c( L-I 1 1 *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inforni1/4, W., pro k,i I nto- rok t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new a davit indicatin such. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or noose emit?e§`IAC-' 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: R.t jc,yL,/ 6 r''G� Policy#or Self-ins. Lic. #: kit) (--C- S-V O- b �$J 71 -•zci2.449 Expiration Date: )21$`2i,,� Job Site Address: 2 77 D;,) c 6-5-i' (. s r p 6-trJ1 O Lill 'f City/State/Zip: y,./"...-p. -Rarr OY).A G 24a 75 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ‘..--- ,-.--- Date: 1 C)// I �__ 7 7 Phone#: S (3 (,g 0 7 Official use only. Do not write in this area,to be completed by city or town official City or Ram_ _Pormit/Lie ns@# Issuing Authority(check one): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector Salumbing Inspector 6.00ther Contact Person: Phone#: • 7894Q46t:"tf ; .•( (.i .(8i9rti!'114 :. L -- — - Wit$" a+ra +32 ,.j k to^nre1Lgip . . : a ... t fw� to;(s ' - --v-. ,. _ • , �793$ �.er a^v'" . �s,Sa•,k (i .,,`� t."f1. _ t . 6 .`fit'.. .Ri2. .,,u: _.•�e:;i,v#; ,:+su _ : . -- - _ • ,fir>#�d`gia ^: tlftllt: �.r >' �y t. o-_=YAK. TOWN OF YARMOUTH =;_ Office of the BuiI4iu Cornmiionr *, r 1146 Route 28, So Yarmouth, MA 02ó64 Aaoa� ais 508-398-2231 ext. 1260 Fax 508-398-0836 "err r 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.Z-217 P 'r c 4r6 Gr'Y t - Pv .- Work Address Is to be disposed of at the following location: i hr ►-I,.c 1•', fir nr6 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. )O///Zi Signature of Applicant Date Permit No. Grcc.✓1 ova CkNienp 6t0;:kr e cDvE To tv 7.7e JI)177 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 210815 THREE PILLARS INC Y Expiration: 01/15/2026 PO BOX 1331 �► --•--;S • SOUTH DENNIS, MA 02660 "" .01110, a a rji ONO Update Address and Return Card. 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: Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 210815 01/15/2026 Boston,MA 02118 THREE PILLARS INC MATTHEW R.COLEMAN 4 BUTLER AVE WEST YARMOUTH, MA 02673 Undersecretary Not valid without signature