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HomeMy WebLinkAboutBLDC-25-102 RECEOILD z Yo Town of Yarmouth Building Departm nt SEP 16 2025 o ' 'y' 1146 Route 28 South Yarmouth,MA 02664 B5 E , -_t,� "-,+�` 508-398-2231 Ext.1261 Fax 508 398-0836 By Building Permit App • 'on for any Building other than a One-or Two-Fami y Dwe©ing R (� his Section For Official Use Only) Building Permit Number:L i �—2Date Applied: Building Official: 7Z—a t' 2" 7 SLCTIONI:LO TION lovkl No.and Street City/Town Zip Code fji.( Name of Buildi g(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 r q fired? Yes 0 No 0 Brief Description of Proposed Work: S4 - i U�clr� lS' Uwt-,� 1111/ 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 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-1❑ 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 CI IB ❑ IIAO IIBO 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 Disposal 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 f Pr per Owner fits& f-e r '.2z , -� 'A vi-2 M O26114 NSme(Print) N .and Street City/Town Zip Prop;; Owner Contact Information: '' e elephone No.(business) Telephone No. (cell) e-mail address a.plic•ble,the property own•r hereb authorizes: G Name Street Address City/Town State Zip to apply for and act on the property ownns.If,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 Gener Contract r \.4 ., Com any Nam G S O e o FL-5- Na ers lesponsible for c s ction cense No. /vt ype if Ap licable Str a Address City/ wn State ip Or3- 7 ar7d6 - - I VS k—e-Al ' ° (A.A1-11 - --U-1---1-- ek usiness No.Telephone b Telephone No.(cell) e-m.'i► '• •_. P (business) 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 $ L1 trOT) Deposit Received$ Date 2.Electrical $ 3.Plumbing $ Permit Fee$ 4.Mechanical (HVAC) $ 5.Mechanical (Other) $ Net Due$ 6.Total Cost $ �`iltfrp Make check payable to Town of Yarmouth SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By enterin my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this a) cation true and a ate to the es of my kno ledge and understanding. )shz S-D7.22, 66 Pleas i and si e Title Telepho le No Date trerevI ss 1 Ci T State i}1 it Ad.iess 23 Municipal Inspector to fill out this section upon applic 'on approval: -�� Name D to TOWN OF YARMOUTH 40(V\ Office of the Building Commissioner r 3' yq 1146 Route 28, South Yarmouth, MA 02664 �'�agPO ° = 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: Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapt 11, §150A. gp 0-v zz) Signature of Applicant Da Permit No. - The Commonwealth of Massachusetts Department of Industrial Accidents __', ►—_ Office of Investigations Lafayette City Center erg . _ 2Avenue de Lafayette, Boston, MA 02111-1750 �.,,� wwx.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizati /I ividu ` i ''o Q 1 ✓�~ Address: �2 8 :-. -- u� �' City/State/Zip: tit, t—\ ©2GC'��Phone #: 0 T / 7 7/6 g cif- A. Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. 0 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. 'fir Remodeling 2.❑ I am a sole proprietor or partner- 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. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.0 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.❑ 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'compens ion insurance for my employees. Below is the policy and job site information. Insurance Company Name: / It4,72jt9bflT Policy#or Self-ins. Lic. #:^- aJ ira ion Date: Q. 2" 1 I 6 Job Site Address: j`'�iL �`-tr )....7 at i : /IAA 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 verificati I do hereby certify er th pains a d penalt' s of perj he information provided above is true and correct. Signature: Date: Ye_ d` `G, Phone#: C 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): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.❑Other Contact Person: Phone #: �oJ `. 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