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HomeMy WebLinkAboutBLDX-26-1063 application vtk,4 i,,.(L.%,- . y kECE1VE ® _____ i. :.-F iO,. o t c SEP 2026 Pt,t�t x� ae-10 , s.tA„ll4o..f..-..9.,_..,4„,,,,,t,,.,,.4.... yir ' Atnot4lt $cA�,a BUILDING DF_I'ARIIViENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)3988-223'1/Ext. 1261 NSTR COitt"rtntu ADDRF,SS i I P LW 1d .JJ r I �/ C.,' C o tiki CD OW'NER:.��. i-c�`I 1 I Rsv,�.n D21'v4► Iv. Y4 MJ7 H NAIVE _..-._. PRESEN i ADDRESS __ _......- Tf:I,. r CONTRACMR: Sco r r R.ettit{N..t1I 9 S'PI N S r. fi)4# f i 6/ 7 -qi SS-G 2G.4 NAME MAILING ADDRESS rE1,.!k EMAIL:C64-t4R, 4i -j3o5 S (0 fM+i/. Cs#i 0 Residential 0 Commercial Cl Est.Cost of Construction S /00 0 — Homeowner is Applicant? Yes No Home Improvement Contract r Lk.# Construction Supervisor Lic.# ._ -t-a c I Al (a m , Olin 2 0 -t-6 © WORK TO BE PERFORMED i---- Q-I Z t>o I' y'2G Tent Duration t (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 penalties of perjury that the statements herein contained are true and correct to the beat of my knowledge and belief: 1 understand that any fake answers) will be just cause for denial or r i on of my lie Re and for prosecution under M.G.L.a.26g,Section I. Q p / Applicant's Sigt+twe: _— Date ! O��t Ovvners Signature(or attachmeat)_ Date: Approved fly: - Date: lluilding(Official(or designcc) Rev 6124 - ' ...AL.; s O lei anti the C"oinmonwe /th of Massachusetts ! - `^r` Department of atdgslrittl Accidents •"7:1`= _ Office of investigations soft .� Lafayette City Center '.,._._... 1 Avenue de Lafayette, Boston,MA 02111-1750 04WW.mass.gov/din Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A &ant Information Please Print L lbl Name(Ilusiness/Orgartizatiort/lndividuat);catering boss)boss grill dba Address:165 market st City/State/Zip:rookiand ma. > 7818039555 Are you an em phone t,: employer?Check the appropriate box: _ 1.❑ 1 am a employer with 4. 0 I am a general contractor and 1 Type of project(required): employees(full and/or part-time).* have hired the sub contractors 6 0 New construction 2.❑ I am a sole proprietor or partner_ listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' 8. 0 Demolition • [No workers'comp.insurance comp.insuranc:e.t 9. 0 Building addition required.) 5. 0 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 myself. [No workers' comp. right of exemption per MGL repairs or additions insurance required.)f c. 152,§t(4),and we have no 12.[]Roof repairs employees. [No workers' 13.0 Other comp.insurance required.) 'Any applicant that checks box al must also till out the section below showing their worker'compensation policy uatr nation. t llomeownens who submit this affidavit indicating they are doing all wort 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.contructors and state whether or nut those entities have employees. If the suh-contractor have employetie&they must provide their wortere comp.policy number. I OM on employer that is providing awi*el 'cempensatlin do urunce fir my employees Below is the policy and_job site information. insurance Company Name:am trust north amenca Policy Nor Self-ins. Lie. N:wwc3864707 Expiration Date:5-1-27 Job Site Address: 11 round drive City/Stater7ip: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 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 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. /do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature. G 9-9-26 phone N: 617-955-6364 Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License N Issuing Authority(check one): f 1DBoard of Health 20 Building Department 3tCitylfown Clerk 41]Electrical Inspector 5Lh'lumbing Inspector 6.DOther ____ Phone 4: Contact Person: COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE 3ROUGHT TO WITHIN 6"OF FINAL GRADE (not to scale) INSP, PORT W/I 3"OF GRADE I 2"of e"to z"DOUBLE WASHED EL.54.0' PEASTONE OR GEOTEXTILE ----.6., FILTER FABRIC 4./-":l 4"SCHEDULE 40 PVC PIPE -FLOW LINE es , (first 2'to be level) 0' 11.5 _21SW1 —y- 34" .{I � J oop00000e00000_ eE.:.n® _I c/ L.53.5' f o°o°o°o°O °°o°o ® EL.51.03' o °o o°o°0000 _ 1.2' ° ° °ogogo tree.,. ®® ERR GAS BAFFLE EL.51.0' °o°o°o°o°o oOo°o° A ,' (H-20D-80X) 000000°oo Q00000 •, " .,a•: INSTALL INLET TEE 6"CRUSHED STONE OR 1"ABOVE OUTLET INVERT SOIL ABSORPTION SK MECHANICALLY COMPACTED (2)500 GALLON H-20 WITH 4'STONE ARO GALLON SEPTIC TANK ....________I....________IU 2"to 1Z"DOUBLE WASHED STONE 12.83'X 25'X 2'CONE (PROPOSED) BOTTOM OF USG GROU ROUND DRIVE 54 56 10.2' 0 0 ' '�"D ,0 A 0 - .4 TOP OF FNDN BENCHMARK: r soa rsEr+o u • EL.58.0' :'# it 6. I 3 i' _ EXISTING o �{ 3 BR o I 1 . �� DWELLING c 1 ' -CLEAN OUTS ) \ 1 1 0 r — -- SCAL id�� LOT 57 14,335 SF± CD 70 —— 56 MAP 28 LOT 169 Ill 54 145.5- r 52 P( NC OF r `� ,r . , d . vvvvvvV\ sy'VYVVYV9v , tvtr < v I � s } , a; 71-. 4 i 34 ac..., ... :,..,. > c w Iii I r .. 0 cig I :, gl 8 1 r a < }} S —�v. E P P t! 5 - b c E a' < ''St i .,g t A g 4 u.,M FAQ °Q Ri $ c 4 ' H .8_ o w vet, 5 s p 7 < 3 O Uea < s . 7 i f- < ` a; 4 _ w i E --VQs << j, N c I - o _ a C u Ld W s 1, a g k t -‹ 2 11 ic We �` E �Gs V� < s 3 r 31•"117":7:4 !s6.9,: hAAA,A kAAA.h..n A.•:1A AAA.AAAA .t•h A r,h,tihhAhhh., SGS Test Report nwraLi.wlx.x0.rx n3enIs.:p,w p.e.xax UT oter& peessee s Tot For Woe&Tm Wrdr.For umylrs T.f _pi 5xx ;Crekso 19p5:So[.en el ml6-Iseyn MwNbn.Ite. Flnroon 001 9rllbq--i _1 1 o e<wrlit«arid_ -- TwYm r. rl'Mlrrw T MAarrue b -I r. ja Na..._ mn► ran58 so NA NO NO j L 69 NIL Ipl Na L Averp 9e4wretner4: DenepedlnpJt Fame rant"iypm 1 Avon.ante/mum tmml Spelimen meevnun Imm More teen 340 „5 2S5 2 No spacemen snap neve on alewelene hoe m mote eve,a seconds Ausa9e aver nary m all apemnans sloe not exceed 2 seconds esdes teal P.M a O alter met mp Iron ma teal spec/mans mans shall not contlnue to name alt omrxrlest cannel. a`'" 5 4t*y4t Fame Mess Loss Creme My well or top material alma mass W lees than 100 p so m are oe tnn deree aeceoude n mo mass loss mono tM teal.s no seater man 5 odcem of the olpnel•.est speurner- T+ssregal•o,the damaged length meas„rement. da re0u•ramnn,nceadee. -spxnnens mat vane unwocnao and unweathered specimens Inert were leadyd but unaeampS oacme s that were weedwed but unkrenered Toe stemdrod mono*moms the regwentan,preecnbed in C991.04 1995 S*choo:1 clause 3 u. 'As five'ned'slapn %marts ..,.A Awn./ Leatln,op a Seceona1-SolonSNnpen water Ian 1x haws 2.WOW tor Si naves Sects,0.?-AccWowod Womhaeeg Prooed.y Iluwmc*M Uv ad coo:m.n.., 0eps rrq uVA'40 lamps eyrie nova al UV et U[,Mµoo t'lo4rr� t.a r.k,•z r.c•w,.•st,..,a. t an'..,.001'usa�,py ran732gl, 0^9 NM,965 boom a poaWm..auemldW sang a rust Mn de the Np yat anleh laaww raa.and.Wean wed ro, yM�'mooted.the l^sa^lmb nwra to es.a on lot ewer a.p«ul relerr,ogoead a.a ,a r.corno ,ded to lost Ne mace v.. //� •_FatlmRpml_• nn sGs No. AJFS1711010519FF Date:NOV.30,2017 Page 3 of 3 Test Report Old rvatfons: Vigorousness of burning No __ Material molten dripping No Odor smoke Yes Gnteria 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 in 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: I e SGS authenticate the photo on original report only ." End of Report— Y n .u..,...1..w rW. Y.N•_M Mry WM.M.i , , .w y� ..7... ,.w NOCY .-. :_zw.w.•.r^Mnr .............................. " ...18 1:21. 4. IsirCl.wMir., .r...r .MY.M MU• ..MWMMMw ==... .•wanMW�+iMyM /zMMNMMwM�W �7'�� =p1 /y l SGS T.$1 fl�p011 i .SHIM 1.06121MINITX Dab:Jun 16.20111 Pow 1 al2 0AN02M)U NW)IIN iNIT1Ax)R Cl).ATD 0AN040U STREET.DAVI 102011,VIIIPNO JIANGStl The 102owe0 2r6OMt,l waswre.utm;FM e(N rdanfed on 6erya a le lien as Semis Dest'01on : lwmnalea PVC mate&lannated PVC tr,wnrw Proposal Care Instructed Teat Peemmnd SeWled NNlsl as r eta,eNwee by appgam • Swap.pacewtg Dew Jun 07,2016 ',estop Patrol Jun 12,2016.Jun 15,2016 Resultlal UNya otervjae stated the results snow,,n fin lael report ewnpws1 tested For tuNwr oateds please.Nw to ine .ale,ageway m l;.e C0n0Weo„ oaow.g wg.;s,. F4,en02tr Test For Was a Top Maw;Ns For Campnp Tentage Products Rwnrka La-Meet Gax,N s Rey;.emem SOISCSTC S1wONds TPchr w:N ServKes(S,rpnal Co.lid 1 �4 PAW kal*CAMI --...—'—_- SGS Test Report Na.AJF9,7t IOlOs19FF o.le:NOV.30,2017 P.s.2 ot'1 I. TM Coneuchd T fa test was mraax+ed e.amar.se wont test method 1 of NFPA 701:2015 SlaMnd 1.1ent0ds of F.. Tea•fur Flame Progwpawon of Ter e1r5 and films. l 1hU6 M 544..E maple Sample desdpeon Cob -VC t.m.&l Moe Ane density 57ed x Parlor eunfpur30e_... SNlpl.las. Sire of sant.• 11501nm.40onm lopes i _ •Wens m •el to e len0 s..ththrees.of ma malenal _—Went the enteS A r Panels InoT g be swage was rord.aoned at least 30 minutes at 105C13C(220 V 25.9) IV.Two oewl4 Spree,I 94104 (11e1E1. I M .f.Aer lest wss. (%) Mr law Ne amino Nra on W 1b•r(.l 36.87 38.01 2.33 0 0 -- 2 36.07 35.55_ 3.05 0 0 3 I 38.85 _.-..3558 2.97 0 0 4 3561 3514 1.32 _ 0 0 5 38.49 35.73 2.00 0 0 0 I 7 3597 3539 1.7E 0 0 • _ 30.ee 3547 3.05 0 0 • _ 39.5 35.70 2.33 0 0 10 38S0 35Cf 3.M p _ 0 _L. 3l.52 -r 3s5 2g SO.0.77 3SO.2p1 Mean,3&D...97 SO-Stan.94.i.syi