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HomeMy WebLinkAboutBLDC-26-64 application RECEIVED JUN 3 0 2026 T wn of Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 ro F J!: sC1 DEPARTMENT i 508-398-2231 Ext.1261 Fax 508-398-0836 Building-Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number:4:',-10C- )""61 Date Applied: Building Official: SECTION 1:LOCATION 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 If New Construction check here 0 or check all that apply in the two rows below Existing BuildingC/ Repairer 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 ❑ No le Is an Independent Structural Engineering Peer Review required? Yes 0 No+p/ Brief Description of Proposed Work: 2e't Ace_ S%hv wit o rL col e 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 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 ❑ F2❑ 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❑ I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10/R-2 0 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 0 I13 ❑ HA CI IIB ❑ IIIA ❑ IIIB ❑ IV CI VA 0 VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit Debris Removal: Water Su ply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site Public Check if outside Flood Zone Indicate municipal 0 A trench will not be Po Private 0 or identify Zone: or on-site system re permit i l or trench or specify: is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or NojEC 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 ame an ddress of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Qtvwct,-- iic‘, Of ;%''t- 000 (.0r7838_ Mo4 ineiikeirAdvit,Ykp Title Telephone No.(business) Telephone No. (cell) e-mail address If jpplicable,the property owner hereby authprize : A_0 G ,(7Gv4-, i Iyiet IAN//Le4oV" /3 hf f 4.ii 10r4 o2Pd/ Name Street Address ity/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) 1.114 ANC GiOV -5LO- )7s`f - C$-r ro1181 Name(R c an , i Tele e I\19. e-mail ac dress Registration Number (3 l.a-I,� wi o 'o( Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor /1_ 04,4e_ fSxTr(AUa L- Company Name iLYi4 tk4V, e,va/ CS.-107t I Name of. sonResponsible for Construction License No. and Type if.Applicable 13 4 C—W — O Street Address City/Town State Zip - - - 40 D-7 44e, c ermiar o / Lt4 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 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Office Use Only 1.Building $ `1 OW Deposit Received S Date 2.Electrical $ ,cam 3.Plumbing $ 0 d 0 Permit Fee$ 4.Mechanical (HVAC) $ 5.Mechanical (Other) $ Net Due 6.Total Cost $ 0 W 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. 0,(_,et -e --42 iteallUt5 01.._ 54-32_- ._•zzsilieb4 Ple prk.t and sign name Title Telephone No. Date 146( Street Address City/Town State Zip Email Address 644, ,,, Municipal Inspector to fill out this section upon application approval: Name Date apileu � KtaK gibta, / , c() o g+:4\ TOWN OF YARMOUTH G_° - oM3z ,Ind ofthe BuildingCommissioner ''` 1146 Route 2 South Yarmouth, MA 02664 �uT7Ara'Ctae.. ��' 9 � <r,°RPOR.t,° ,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. e(.0 q ki ..- (9-56 Work Address Is to be disposed of at the following location: ()'U / - Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. i (,)gy,„Ct_.../c7LerA,J....--- 6ii Signature of Applicant Date 1 Permit No. 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 Vyix 1 *- / 1/45-Ob 362 4-6410ee wm1- c—1 L- Na egistrant) Telephone No. e-mail address (,4.44141, 6.7 _ Registration Number v9- /r Discipline Expiration Date Street Address City/Tovfn State Zip 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. i ne t.ommunweuttn uj wlussucnuseus ,_ Department of Industrial Accidents it. f r..-.-. r=; Ofce of Investigations 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 / / Please Print Legibly Name (Business/Organization/Individual): I /,, ,/ ktrt/ _ Address: / cJ6 /3 6; C C 4 5,i l— City/State/Zip:7 01W//1 15 0,2 60 o/ Phone #: L3 2 36002 ,,j Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 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. ❑ Remodeling 2.❑ T 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 10.0 Electrical repairs or additions officers have exercised their 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *Any 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: / Ve /e.,g6 Policy#or Self-ins. Lic. #: i/ k. a / 9'7?1' yjp?6 Expiration Date:�j/16/20o Job Site Address: C- 6 /o/--e d e 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 certi under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 6/3% Cy90c2. Phone#: 36 O 0? Py 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): 11:1Board of Health 20 Building Department 3.0City/Town Clerk 4.1=1Electrical Inspector 51Thlumbing Inspector 6.0Other Contact Person: Phone#: �® DATE(MM/DD/YYYY) AC `O CERTIFICATE OF LIABILITY INSURANCE 06/30/2026 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 James Hindman NAME: WORLD INSURANCE ASSOCIATES LLC PHONE 508 771-8381 FAX _LAIC No EA* (A/C,No): _—.—_.--—_-- -- E-MAILADDRESS: ) m y man@ im hind worldinsurance.com 656 Shrewsbury Ave suite 200 INSURER(S)AFFORDING COVERAGE NAIC# Tinton Falls NJ 07701 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: LAVRENOV ILYA INSURER C: DBA A GRADE EXTERIOR SOLUTIONS INSURER D: 13 BIRCH ST INSURER E: HYANNIS MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: 1235102 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 MAv 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'. IADDLISUBRI POLICY EFF I POLICY EXP LTR i TYPE OF INSURANCE I INSD WVD POLICY NUMBER (MMIDD/YYYY)i(MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABIUTY _ EACH OCCURRENCE •$ bAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY j1J JEC I I LOC PRODUCTS-COMP/OP AGG $ 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 —a AUTOS HIRED ONLY AUTOS NON-OWNEONLY D PROPERTY DAMAGE (Per accident) $ _. $ LH UMBRELLA LIAR OCCUR I EACH OCCURRENCE I$ EXCESS LIAB CLAIMS-MADE N/A I I AGGREGATE I$ i DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ---------------- �ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 7PJUBOW99084326 05/16/2026 05/16/2027 (Mandatory in NH) ' E.L.DISEASE-EA EMPLOYEE! $ 500,000 If yes,describe under ''. DESCRIPTION OF OPERATIONS below 1 E.L.DISEASE-POLICY LIMIT I $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation 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- com pensation/i nvestigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MA-28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crowley,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 Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards • Constkyteon 4toervisor CS-107181 Tires: 05/27/2025 ILYA LAVRE(OV 13 BIRCH STREET HYANNIS M/ :2601 raL��IJ,t"3 13' Commissioner s• — C 4-- � I I