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Home My WebLink AboutBLDX-26-1062 application f - RECEIVED cilfiee use Chrly of -� P 2026 pert„,,„ t _ oc" Amount 5 � A KiriY O —.. .°""`O>% BUILDING DLF'ARTMENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508►398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 11 round drive oWN1 R: tracey kae al C.93(de\c o NAME PRESENT'ADDRESS TEL it COO RAC1.OR- catering boss 8 spring st hanson, ma. 617-955-6364 NAME; _ MAILING ADDRESS TEL N EMAIL. cateringboss@gmail.com X3 Residential ❑Commercial 1 I Est.Cost of Construction$ i U 0 0 Homeowner is Applicant? Yea No x Home Improvement Contractor Lie.# Construction Supervisor Lie.# liaqrnall . (ft 0,0 WORK TO BE PERFORMED VJN It Tent X Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structure Solar System ESS System Chimney Fence *please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review *the debris will be disposed of at: Location of Facility I declare under p wattle*of perjwy that the statements herein contained are true and correct to the best of my knowledge and belief t understand that any false answsrts) will be nut 4 4 vw for dui or ravucation of my license and lirr prosecution under M.G.1..Ch.268,Section I. p� 9-9-26 Applicant's Si sure. .r."_.a Rate: Owners tiig store(or sunchmest) Doe: Approved try: Aao: Building Official(or designee) Rev 6124 lire Commonwealth of Massachusetts ts Department of Industrial Accidents _ Office of Investigations ` ,-�✓ Lafayette City Center 2 Avenue de Lafayette, Roston, MA 02111-1750 ivww.nto Workers'Compensation Insurance Affid t`a Builders/Contractors/E:lect ' A besot Information rtctans/plumbers Please Print Le►ibl Name tnusinesstOrgaruixationfindividuai):catering boss/boss grill dba Address:165 market st City/StateJZi : kland ma. 7818039555 Are you an employer?Check the appropriate box: Phone#: 1.❑ Ian)a employer with— 4 O 1 am a general contractor and I Type of project(required). 2.0 employees(full and/or part-time).* have hired the sub-contractors 6. O New construction I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have working for me in an y g• 0 Demolition capacity, employees and have workers' [No workers' comp,insurance comp.insurance.2 9. ❑Building addition 3.❑ required.) 5. O We arc a corporation and its 10.0 Electrical repairs or additions tam a homeowner doing all work officers have exercised their 11.0 Plumbin re myself. [No workers' right of exemption !� parrs or additions f comp. g per MGL 12.0 Roof repairs insurance required.] c. 152,§1(4),and we have no employees, [No workers' t 3.❑Ot lfercatering comp.insurance required.) *Any applicant that checks box#1 must also GU out the section below showing their workers'compensation policy informat um. t 1(om:owners 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 ohm showing the name of the sub-contr ctors and state whether or not those entities have employees. if the sub-contractors have employes.they must pmvitk their workers'comp.policy number. t ape an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site information. Insurance Company Name:am trust north america Policy tl or Self-ins. Lic.#: e38647g7 _ Expiration Date:5-1-27 Job Site Address: 11 mend drive City/State/Zip:w—Yarmouth Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Faihtrc to secure,coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 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 ofpetjury that the information provided above is true and correct. Signature, Pate. 9-9-26 Phone 4: 617-955-6364 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): 1OBoard of Health 20 Building Department 30Cityirown Clerk 4nElectrical Inspector 3E}lumbing Inspector 6.0Other Contact Perron: Phone ti: _ I he Commonwealth of Massachusetts. Department of Industrial Acciden& • ...-7_7:-.-- .-____ly., 41' Office of Investigations ILafayette City Center •;...iF 1 Avenue de Lafayette, Boston, .'WA 02111-1750 A.,,.,!, FV14,ht,mass.gov/dia Workers'Compensation Insurance Affidavit: Buildcrs/Contractors/Eleetricians/Plumbers Applicant Information Please Print Le,ibl Name inusioms'orpoimiorvindivId• uan:catering boss/boss grill dba _. Address:165 marital st City/State/Zi ;rockland ma. Phone#:7818039555 Arc you an employer?Check the appropriate box; Fy. : 1,0 1 am a employerct with 4. 0 I am a general contractor and I pe of project (required) employees(full and/or part-time).* have hired the sub•contractors 0. 0 New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Dcmolition working for me in any capacity. employees and have workers' . 0[No workers' comp.insurance comp. insurancet 9. Building addition requirtd.) 5. 0 We arc a corporation and its 10.0 Electrical repairs or additions 3.0 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.] ' c. 152,§1(4),and we have no employees. [No workers' 13.0 othercatering comp. insurance required.] Any applicant that checks has it I must also fill out the section below.showing their workers'compensation policy inhumation. I him:owners who submit this affidavit indicating they are doings!!wort and then hire outside contractors must submit a new affidavit indicating such, :Contractors that check this box must attached an additional sheet%ho's trig the name of the sub-contrition and state whetha or not those entities have employees. If the sub-contractors lave employsxs,they must provide their workers'comp.policy number. I am an employer that is providing WOIlifri.compensation insurance for my employees. Below is the policy and job site informarion. Insurance Company Name:am trust north amenca Policy 9 or Self-ins. Lie. #:wvic3864707 Expiration Date:5127 Job Site Address; 11 round drive City/State/Zip:w•Yarmouth 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 MC.iL c. 152 can trail to the imposition of criminal penalties of a tine 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 tine of up to S250,00 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 cern:0 under the pains and penalties of perjury that the information provided above is true and correct. Signatutc: — 1)/Ito: -26 617-955-6364 Phone#: _ Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License it ! - Issuing Authority(check one): 1 1[3Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector Cinumbing Inspector 6.00ther Contact Person: Phone ti: _ . ..„ .._. COVERS TORE WATERTIGHT AND SEPTIC SYSTEM PROFILE 3ROUGHT TO WITHIN 6"OF FINAL GRADE (not to scale) INSP.PORT W/I 3"OF GRADE 2"of e"to Z"DOUBLE WASHED EL.54.0' PEASTONE OR GEOTEXTILE ---` FILTER FABRIC ^,i .4/- , .q 4"SCHEDULE 40 PVC PIPE FLOW LINE n WW2'to be level) A. 14" y., ,Qooa0000000aoo-n �• �q 1 —�- a o°00000 0 o e'® Cam® � L.53.5' ' 0 000_ ® ®� I EL.51.03' 'oo 00°o°o°o00 E 51.2' �_� o o°o°o°o°o°o°o El En ®'� GAS BAFFLE EL.51.0' ,0o°o° ° °o °° °.4 4 ••-• (H2O D-BOX) pgo°o°o°o° o°o°o°' • . ...4 •,INSTALL INLET TEE 6"CRUSH D STONE OR 1"ABOVE OUTLET INVERT SOIL ABSORPTION SY. MECHANICALLY COMPACTED (2)500 GALLON H-20 WITH 4'STONE AROUP GALLON SEPTIC TANK 4"to 1Z"DOUBLE WASHED STONE 12.83'X 25'X 2'CONF (PROPOSED/ BOTTOM OF USG GROU ROUND DRIVE 54 56 10,2' illir- 0 0eTH-I "'i rir-- r BENCOF FHMARK:NONsoe erovx TOP EL.58.0' a 8 11. 3 „ ' , I EXISTING j l I tA 4 via 3 BR DWELLING I 111 ) l 'CLEAN OUTS 0 - - I SCAL `‘ LOT 57 (q[J 14,335 SF± ——_J 56 MAP 28 LOT 169 I<11 — _ 54 14558' _ _ , 1 ausipripossiimr 52 PL NC OF I YV "'" VVVVVVYYVVVVYV'V ,,,:i,vV'v.vYVVVYYYVVVYVYVY' <. .8,� < ;. i i I _. < e L. < t E i j :?: < c c' i - C nu tF. .v < r 0u < m Y, <} it 'ee 7 3 p a , it o r A t:` sg ` � 4 t a <; F. � 3 _ 31 ; .0 M i^j me g9 e, u Re q I i gypp: t C E U 3 g g U a r o. ' m — 6,010_ y Y dfli 4 - Yq< 1 H V r+a p r L H 2 { Rio 2 . A i .a 1 - 3 c... Z. -- 8E a $ s : .....3 < 4AA AA A nA fr..A AAA A/ AAAA.AAAAAAAAAAARAAAkitAAAAA�IAAA ` SGS Test Report Ito.SI M f1g129ge9Tx horn Jun rs.2005 aaea s et � TediBOYe reeneelt9 Tee For RI111.ITl3N5tlePRsFun Can AMR TANASPiNNANPI r A+sl 1945 S0Aor 1l AL90ket _ D tnarys,f h T— 711trie lame uma t Fla+srq dose w llmlq� Sperm, 72 0(1e nI nI Al I erc�tnrase pNFldatlle j Ler0KrMN Y-Y%sAIY NIL 1el No _ 56 6l'. NLL_. No 3 56 58 NB tt, No __. a —63. I_ 69 NIL NilNo Requeements I.Damaged Length Fates aapllt 1pepmr Area m Imm) Specimen Ibre Men 3S0 ears um 255 roan 2 No spacemen shall heme an ahll-I arse hm0 a nee tan a seconds. 3.Average a M d a er flame apla rot exceed shall exceed 2 seconds. a Pomona eedes Mat beak w ell from de lest specimere shall not coopnee to flame alter they reach me Soot et'se*sl cablN. 5 lapnwey'Fasx Mass Loss Cr ta,e.Any sal or top maltreat met a mass of Ion than 100 p sal m.se Pe consl0erep acceptable n the mass less damp fro teat a no preabr than 5 percent of Me onpnW Iosl spec,mer mass eprleaa el IM damaged length mesaurement 6 Tres rsprrementn ,se -apxenens Inat were unleashed and urlsealhored shamans that were leveed but umweatrlered -spe;Ime s that were sorehead tut w,leacnred Comment TM srgndbd sample meets Me rp.Hremertl pleated st CPAI-Al 1995 5ashon 3 clause 3 As Reaeed'stases Remake Remelts I.LeaCbro procedure Serlon 41-SWnerpro m was lw 72 lours W54.1699 Wo g.Secswn a.%-AttllaNad Weelhr.19 erarz0ae rtuees..W and CeoarAses, Meeed.for 54 does leo cycle 8 Mars Al W at Ile degree I totorr1 pr a sours or condarsa.l.al ht 9 drys.Cthe ✓,sno INA-340lamps ao !.or swop¢Is 7329 m .assorWr9 o CGALM 1996 Bea.!prra:aiae aohnNRed earryan meat he do the hurl rear w03h ncade toques.Md s+whereon isAsAse s l ad stow 00eltlawrW TM Irrcmpyaa method Is erwe un 1M Lanese apes'Ier +pmhbb prw:vdpna ll la wcom...F.1 to lee*A procedure, ...(.bur Nalnorl..• SGS SGS Test Report No.AJF31711010519FF Dote:NOV.30,2017 Page 3 of 3 mb^s: Vigorousness of burning No Material molten dripping No ------ Odor smoke Yes Criteria for test method 1 (Chapter 101: 1. Fragments or residues of specimens that fall to the floor of the test chamber shall not continue to burn for more than an average of 2 seconds per specimen for the sample of 10 specimen. 2 The average weight loss of the 10 specimen n a sample shall be 40 percent or less. 3. No individual specimen's percent mass loss shall deviate more than 3 standard deviations from the mean for the 10 specimens. 4 When a retest is required,no individual specimen's percent mass loss in the second set of specimens shall deviate from the mean value by more than 3 standard deviations calculated for the second set. 5 When a sample does not demonstrate passing performance in accordance with all of the conditions Indicated above,the material shall be recorded as having failed Test Method 1. Photo Appendix: r I p F SGS authenticate the photo on original report only "'End of Report"' UrM..IIrMN r.r M.+'ry.M rR.�..�,r we* r rr+..N GMIMrr ay ll,:. 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