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Permit expires 6 months from
l issue date.
EXPRESS BUILDING PERMIT APPLICA IONC E I V 1:
TOWN OF YARMOUTH I
Yarmouth Building Department OCT 22 2014
1146 Route 28
South Yarmouth, MA 02664 N
(508) 398-2231 Ext. 1261 `-- ----
CONSTRUCTION ADDRESS: 2.nv-I SOJTH s wa(2z- 'pe-.A \jF- , S, N {&nL LauT;eS
ASSESSOR'S INFORMATION:
Map: I Parcel: 127;�
-t�)1Cr 0V&NNS.SktCDP-6 •DLL.LC- I+
NAME
LN
CONTRACTOR: �?A)L 5 C Av2Ze kuL T- M A\
NAME / MAILING ADDRESS TEL # UZ�SS
❑ Residential ereial ❑ Est Cost of Construction
Home Improvement Contractor Lie. # i 0 3 't'1 (4 Construction Supervisor Lic. # C. S - C)2� 'SO? S"
Workman's Compensation Insurance: (check one)
❑ lam the homeowner ❑ I am the sole proprietor ve Worker's Compensation Insurance
Insurance Company Name: L M 1 N S. Lo K P Worker's Comp. Policy# W �-S ^ 3 IS - 3 8(4-X) -02M
WORK TO BE PERFORMED
❑ Tent (Fire Retardant Certificate attached) P.D k P V 3 (3- - C-00 F ❑ Wood Stove Shed
❑ Siding: # of Squarer ❑ Replacement windows: #
❑ Replacement doors: #
ie-roof. # of Squares ❑ Insulation
( �B Aping old * () going over layers of existing roof ❑ Old Kings Highwayffstoric District
Roofing/Siding (Like for Lure)
'the debris will be disposed of at: QC HMO UT 1
Location of Facility
I declare under peaaltics of perjury that the statements herein contained are true and correct to the best of my knowledge and belie£ I understand that any false amwer(s)
will be just cause for denial or revocation of my license
�and
�for prosecution under M.G.L Ch. 268, Section 1.
Applicant's Signature: �CW—Q C,og�,Q Date: ,b,?�I �L(
Owners Signature (or attachment) Date•. r 0
Approved By: Date:
Building Official (or designee)
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 R of Wetlands:
❑ Yes ❑ No ❑ Yes ❑ • No
r'�
3/01
The Commonwealth of Massachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
< www.mass govhUa
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information PIease Print Le�iblY_
Name (Business/Orgadzation/IndividuaI): pA V e, j, U`i ZLrA-v LT- -fSv ^1 S
Address: /O 3j
City/State/Zip: O 1%1/t- Phone #: Z i
an employer? Check the appropriate box:
AFam
a— -7
Type of project (required):
1. a employer with r wT«B is
4. I am a general contractor and I
6. El New construction
employees (full and/or part-time).*
have hired. the tacked sheesub-contract ors
�� °II the �� sheet.
�� � Remodeling
2. ❑ I am a solo proprietor or partner-
ship and have no employees
These sub contractors have
g. Demolition
working for me in any capacity.
employees and have workers'
insuran°eJ
9 Building addition
R• b workers' comp. insurance
comp.
5. We are a corporation and its
IQ. El Electrical repairs or additions
re
required-]
3. ❑ I qu a homeowner doing all work
officers have exercised their
• 11. [] Plumbing repairs or additions
myself [No workers' comp.
right oferemptionp;rMGL
12.QRaofrepairs
insurance rccpared.] t
c.152, § 1(4), and we have no
13Other
employees, [No workers'
*Any applitaut that checks box #1 must also fill out the section below showing their wo]kers• oompcasanon poucymmrma.,uu.
t Homcowncrs who submit this affidavit indicating they are doing all work and then hire outside eon4etor, must submit anew affidavit indicating such -
=Contactors that check this box must attached an additional sheet shpwingthe name of the syb-co ha rs and state whether or not those entities have
cmployms. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an emplgyer that is providing workers' coupe sadoir insurance for my employees Below is the policy and job site
information.
Imurance Company Name: LA4 /N Sc/�c7VG £. Ga1Q l�
Policy # or SeLzins. Lic. # h/CS — 3 / S — G 6 70 ^ Z P.apiration Date:
Job Site Address: a7� '50Lrr ! S NoZ.Z 1)tely � City/Statamp: `1 � � i MP►
Attach a copy of the workers' c mpensation policy declaration page (showing the policy number and expiration date).
Faihae to secure coverage a$ required mider Sogdon 25A of MGL a 152 can load to the imp6sition of Mammal penalties of a
fine op to $ I,500.00 and/or one-year imprisonment, as well as civi7'penaltics in the fo>m of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violater. Be advised that a copy of this statement may be forwarded to t4, Office of
Investigations of the DIA for inst_um= coverage verification.
Ida hereby certify under tha pains and penalties ofperjwy that the informadan provided above is true and correct
e41... J Sr_ U? L—
Official use only. Do not write in this area, to be completed by city or town officiab
City or Town:
Permiturense
[c)
Issuing Authority (circle one):
1. Board of Health 2. BuiildingDepartment 3. City/Town Clerk 4. Electrical In$pector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
I Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
CnnslrucUunSupcn-kor
License: CS-026325
PAUL J CAZEAUP'r
1031 MAIN S;( 1 4�
OSTERVILLE NfA 026
. . •/Y �.1rJi ``7
Expiration
• Commissioner 10/20/2015
r
= �e vol))Nnovz ea� a C%��tzclJacl �e
Office of Consumer Affairs and Business Regulation
� 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 103714
Type: Private Corporation
Expiration: 7/9/2016 Tr# 254237
PAUL J. CAZEAULT & SONS, INC.
Paul Cazeault
1031 MAIN ST
OSTERVILLE, MA 02658
sCA1 a 20nwe11r
��c �unruonux•a�(� r�'G`flntinr�u�r/li
Office of Consumer Affairs & Business Regulation
OOME IMPROVEMENT CONTRACTOR
gistion:: 120i6 Type:
Rom. piration: 7/9/2016 Private Corporation
AUL J. CAZEAULT & SONS, INC.
ui Cazeault
31 MAIN ST 4
TERVILLE, MA 02658 UndL
ersecreury
Update Address and return card: Mark reason for change.
Address Renewal Employment Lost Card
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, NIA 02116
Not valid without nature
11 ov CERTIFICATE OF LIABILITY INSURANCE
DAT 8f7/2DDIYYYY)
annals
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 cerUBcate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. It 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 endorsements .
PRODUCER DOWLING & O'NEIL INSURANCE AGENCY INC
973 IYANNOUGH RD
PO BOX 1990
HYANNIS, MA 02601
NMEACT
PHONE FA%
A�
E-MAIL
INSURERS AFFORDING COVERAGE
NAIC /
INSURER A: LM Insurance Corporation
33600
INSURED
PAUL J CAZEAULT & SONS ROOFING INC
1031 MAIN STREET
OSTERVILLE MA 02655
INSURER B :
INSURERC:
INSURER D:
INSURER E.
INSURER F:
COVFRAGES CERTIFICATE NUMBER: "IAR147 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 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
TYPE OF INSURANCE
DOL
BRPOLICY
NUMBER
MMLI pY EFF
MMLICY E%P
LIMITS
COMMERCIALGENERALLIABILITY
CWMS-MADE OCCUR
EACH OCCURRENCE
$
MED E%P one aeon
S
PERSONAL &ADV INJURY
$
GEN'L AGGREGATE LIMIT APPUES PER.
POUCY 0jEa LOC
OTHER:
GENERAL AGGREGATE
S
PRODUCTS AGG
S
S
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED AUTOS
AUTOS NON -OWNED
HIRED AUTOS HAUTOS
COMBINED SINGLE LIMIT
IEs
$
BODILY INJURY (Per person)
S
BODILY INJURY Per aradent)
S
PROPERTY DAMAGE
(Per acodentl
&
f
UMBRELLA LIAR
EXCESSUTAB
OCCUR
CLAIMS -MADE
EACHOCCURRENCE
S
AGGREGATE
S
DED RETENTIONS
&
A
WORKERS COMPENSATION
ANDEMPLOYERSLIABILITY YIN
ANY
OFFICEOPRIET RPE%CLUDE I EC�� ❑N
(Mandatary In NH)
If yyea If under
DESCRIPTION OF OPERATIONS below
NIA
WC5-31S-386670-013
WC5-31S-366670-024
8/10n013
8/10/2014
8/10/2014
8/10n015
PERTUTE TH-
E.I. EACH ACCIDENT
S 1000000
E.L DISEASE - EA EMPLOYEE
S 1000000
E.L. DISEASE -POLICY LIMIT
S 1000000
DESCRIPTION OF OPERATIONS I LOCATIONS) VEHICLES (ACORD 101, Additional Remarks schedule, may be attached B more span I. mquimd)
Workers compensation Insurance coverage applies only to the workers compensation laws of the slate of MA.
This certificate cancels and supersedes all previously issued certificates, only as they relate to workers' compensation coverage
r:FRTIFIr:ATF Hnl nFR 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.
AUTHORIZED REPRESENTATIVE �. ^ +
�t a
LM Insurance Corporation
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
CERT NO., 21146142 CLIENT CODE: 1614182 Lucy Garfield 8/1/2016 2:4:49 PN fEDT) Page I of 1
10/20/2014 11:08 5083982910 SKrPPYS PIER I PAGE 01
s
fP"
Property Owner Must Complete & Sign This Form
If Using a Roofer / Builder.
/ 6,ia�rhe- 7/.
as Owner / Agent
of the subject property hereby authorizes Paul J. Cazeault & Sons Roofing Inc.
to act on my behalf, In all matters relative to work authorized by this building
permit application for:
Address of Job
Signature of Owner
Z-,V* Sov7w S HcaE Die-%NJE
Mailing Address of Owner P 6• SO)( 3 q o
S-
Telephone # (q
Da
a6
A,eu-4-a u7?t
I
Please return this form to Paul J. Cazeault Roofing along with your signed contract.
It is needed for us to obtain the building permit required by your town to complete your roofing project
Fax #508-420-4555
offlcencezeault.com
I
BUILDING PERMIT APPLICATION
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE. CHANGE THE USE, OCCUPANCY OF,
OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Totvtl of Yarmouth Building Department
1146 Route 28 • N'arnuntih. NIA 02664-4.192
Tel: S0&398.2231 ext 1261 Fax 508-398-0836
Nicehh�� Planning Board Information Assessors Department Information:
Permit NDate Grf� TypetoPermit Fer Endorsement Dateording Date New
Deposit Recd. $ Date I P n No. 1.4 Property Dimensions:
Net Due $fir --7e-w ,� 0 er Lot Area (sf) Frontage (tt) Lot Coverage
This Section for Offtca Use nty
Building Perm'PermX Number.
Date Issued:
02 ;t'Q —/
Certificate of Occupancy
Signature:
auildng Official Date
is is mquM
Section 1 - Site Information
1.1 Property Addnsst 1.2 Zoning Information:
^
Zoning District Proposed Use
1.3 Building Utbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Re u e
1.4 water supply (&LQ.L. c. 40. s s41 1.5 Flood Zwe Informed«, comments EB 20 2014
Public Private Zone: BFE
Section 2 - PropertyOwnershi Authorized Agent au LDINc EPARTMENT
2.1 wner/of Records ^ . 0.
C1,7
Name (print) Mailing Address:
Signat re Telephone Telephone'
2.2 Authorized Agent:
2 Stl,7 .P
N prin s'aF-5�q r-�oSS Mailih4 dd ess:
Signature Telephone F4
Section 3 - Construction Services
3.1 Licensed Construction 3upervison-
0 s e. -/-- j3 % 4 S ej a 6
1,31r,04
/d sj1d12204
9 Fs -
Not Applicable
License Number
ES. o7is7(
Expiration Date
7-/ PC/S
t of 4 OVER
3.2 Registered Ho a Improvement Contractor. -•�
Company Naa»
Not Applicable ❑
3 r 4 li Dy Regis n Number
Add c �+ S % 7 e
7i1 � fro rF - C �- C S Expiration Date
Sl ature Telephone - 2 Z " (i
Section 4 - Workers' Com ensation Insurance Affidavit (M.G.L c.152 S 25C (5)
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached Yes .......... No ..........
tec6on.5 - Professional Design and Construction Services - for Buildings and Structures Subject
Construction Control Pursuant to 780 CMR 116 (containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect
Not Applicable ❑
Name (Reyrstront)t Registration Number
Address
E�iretion Data
Name
Address
of
Registration Number
cs....ne.rs Telephone IExpiration Date i
Name
Address
Signature
Telephone
Name
Address
Signature
Telephone
Name
Address
Signature
Section 5.3 General Contractor
Telephone
Company Name
Person Responsible for construction
Address
Signature
Telephone
Registration Number
Expiration Date
Area of Responsibility
Registration Number
Expiration Date
Area of Responsibift
Registration Number
Expiration Date
Not Applicable ❑
_. 2 of 4 . .
Section 6 - Description of Proposed Work (check all applicable)
New Construction ❑
1 (for multiple family only) No. of Bedrooms
(for multiple family only) No. of Bathrooms
Existing Bldg. ❑
Repair(s) ❑ I
Alterations
Addition ❑
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work: _ _
en d►- n 4 un % S O — OS — oZb ` a�S
ab
Section 7 - Use Group and Construction Type
Building Use Group (Check as appficapable)
Construction Type
A ASSEMBLY
❑ A-1 ❑ A-2 ❑ A-3 ❑
Al ❑ A-5 ❑
1A ❑
is ❑
B BUSINESS
2A ❑
213 ❑
2C ❑
E EDUCATIONAL
❑
F FACTORY
❑ F-1 ❑ F-2 ❑
H HIGH HAZARD
❑
3A ❑
3B ❑
1 INSTITUTIONAL
❑ 1-1 ❑ 1-2 ❑ 1.3 ❑
M MERCHANTILE
❑
4 ❑
R RESIDENTIAL
❑ R-1 Cl R-2 ❑ R-3 ❑
5A ❑
sB Cl
S STORAGE
❑ S-1 ❑ S-2 ❑
U UTILITY ❑ SPECIFY:
M MIXED USE ❑ SPECIFY.
S SPECIALUSE ❑ SPECIFY:
Complete this section if existing building undergoing renovations. additions and/or change in use.
Existing Use Group:
Existing Hazard Index 780 CMR 34
Proposed Use Group:
Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area
Building Area Existing (if applicable) Proposed
Number of floors or stories
Include basement levels
Floor Area per Floor (sill
Total Area All Floors (sf)
% it
Total Height (h)
Section 9 - STRUCTURAL PEER REVIEW (780CMR 11011)
Independent Structural Engineering Structural Peer Review Required Yes .......... No ..........
SECTION 1 Oa OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property,
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
?iinature of Owner Data
.of.4 OVER --
SECTION 10b OWNER/ AUTHORIZED AGENT DECLARATION
1. elop s e n-t-- %"G S @s h V
, as Owner/A horized A en
hereby declare that the statements and information on the forgoing application are true and acurate, to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
2eS may— F 5 Cr r7 v
Print Name
�vy�
/ —1 ) 7,
,21=�
Sig ture of Owners gent
Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Rem Estimated Cost (Dollars) to be
completed by permit applicant
1. Building
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
S. Fire Protection
8.Total .(1+2+3+4+5) 00
7. Total Square F2 Ibn wumn a+sw+i
Check Below
❑ Conservation -Commission Fling
(if applicable)
❑ Old Kings Highway b Historical
Commission approval
(if applicable)
_.__ _ 4of4
• The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AfA 02111
www.masxgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers
Applicant Information Please Print Legibly
Name (Blumeworganizadmindividualj. / Ca r — % Ne. s c, ny
Address: a 131 ;,
u , J �� e 4_ rv1 rry— o? v vs Phone#: uri 2
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with • 4. ❑ I am a general contractor and I
,employees (full and/or part-time*
2.0 I am a sole proprietor or partner-
ship and have no employees
worsting for me in any capacity.
[No workers' comp. insurance
reqdrc&]
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
insurance l 1 ♦
3a.0 I am a homeowner acting as a
general contractor (refer to #4)
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp, invmanCe.:
5. ❑ We are a corporation and its
officers have exorcised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
coma. insurance reuuired.l
Type of project (required):
6. ❑ New construction
7. [aRemodeling
S. Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
i 1.0 Phmibing repairs or additions
12.0 Roof repairs
13.0 Other
•Any applicant that checks box #1 most also fill out the section below showing their worms' compensacodtoiicy information.
t Hcmeawnea who submit this affidsvit indicating they am doing all wode and then hire outride connectors most submit a new am avit indicating such.
t ronnaerats that check this box mast attached an Sdditional shed Showing the name of the Sub-eonnactoo sad state whether or not those entities have
employees. If the somas have employees, they must provide their workers' comp, policy number.
Ian an employer that is providing workm' compensation insurance for my employees. Below is the poRey and Job site
informadom
Insurance Company Name.
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/Stateop:
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 e. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK'ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby cerdfy
G
Phtlne#, So 3 3 S- 5= 3 z 5
of perjm y that the vrformadon provided above Is true and correct
Q chd use only. Do not write in this area, to be completed by city or town official
Clty or Town: Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. CItyfrown Clerk. 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
Information and Instructions z : --
Musschnxttz General Laws chapter 152 requites all empty& to provide wMk*=' compens tot; their employees.-
Piasuml to this statute, an emplgw is defined as "_cvuy person in the service of mother under any contract of hire,
egress at implied, oral or written."
An topky ► is defined as "air individual, parts T&* assocfaflM corparahaa oc other heel eaft of any two or tore
of the foretocrs eapge d in a joint calerpcisR and imbding tfwkplrepmwnwimofadmetwdcmpbMottbs
receiver at trmtet of n bdirido4 partnership, anoe:stim at other kW entify. cmploYittg CmPbYm& Mmnw the
owner of a dwelling house baying not mace d m three apatments and who resides thasi% at Hts occupant of the
dwelling Mass of another who employes peraooa to do m t atenaace, cem" -$' or repair wont on inch dweltiag house
at on the paunch cc bandies; appurtenant thereto shall not because of such employment be deemed to be in employer"
MGL drapes IS2, f 25C(6) dw states the "cm7 state ire hwd ileemta; tPuY Air wlt bU the tssassee or
renewal of a tknn or permit to opssattt a bedow or is eoaetrud b%Nbp to the assaoawesltft fir e4
appiietat wM has not pradoai seeeptable "Wes" of amptfnsee wfth the lamwm anersp regstrW
Additionally. MOIL chapter 1A 123(x'n stains -Neither the commonwealth nor airy of its political subdivisions shall
eats intosay eonhsc! fat the peckrosonce of pubiie wady untt7 acceptable evidence OfCOMPHI= with the insuranea
requirzm� of this chspta have bees presented to the cmkw ft asrthacily."
- - APPUessb ---
Please IM oat the woriaa• compeasstiam affidavit comply, by checking the boon that apply to your situation and if
necessar7. nippy sub-eoOtrsctae(s) names). addtssa(es) and phaoe number(s) elm with their cati&2te(i) of � -
iatrasaes 1Lisaited Liability Companies (LLQ a Limited LWHIiI Pattoa'shiP (L.LF) with so emPbyees other thm the
members or peraws, as not required to carry works' eompea 'din h =MML If an LLC at LIP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Dial
Accidead fat confirmation of faserance covemIL Abe be mra to sip and date the alDdavfL The atIIdsvit should
be relt:ned to the city or taws that the appuczd a for the paw$ or }ice . Is being requested. net the Department of
Indnaeial Aecideaes Should you have any questions reptdi the law or ifyou an regmrW to obtain a auksts'
comps ii m - po1%y. please call the Depaunag ai the ghee 161md below. SelfUm-ed eampaaies sboaid POUT their
self-hmov o license number on the Emsegm rn._
City or Tows OfWab
Please be sun that the affidavit is cOMPL- a and printed kg'bll . TI* Department has provided i space at the botbm
of the affidavit for you to fill out in the event the Office of ravestiptions has to contact you reprding the applicant;
Please be sure to fill is the permit4kease numbs which will be used as a refurace nambez; Ice additim m aPPH
that moat submit multiple permitliianee aPPiicadOw is my glom year, need only submit nos aHsdavit indicating cuasat
policy inlar=dm (if necessary) and under "Job Me Mhes" the applicant should wrist "ill locations is (city cr
town)." A capy of the &Mdsrit that has been officially el pp d a muted by the city a tows may be pQvidod to the
applicant is pouf that i valid aifidarit is ca Ms foc ![three permits oc liecum A new of advit must be filled out each
year. When a home owns of cid= is obtaining a license a permit not related toany budoen orcomimercial veate:s
(Le a dog lieense or pesflut to buts Imo ate.) said person is NOT requked to complete chit LMdsviL
The of&e of lavesdgidm would lirat'to thank you is advmce far year cooperation and should you Imvi my Ill, one,
pleas do not hesitate to give as a c M
the Depsrtmmt'a address, telephone and cis tarmba:
The Commonwealth of Musachusetts
Department of lWastrial Accidents
OtDa of Iarttidptieas
600 Washington spree
Boston, MA 02111
Tel. Ji 617-7274900 ext 406 or 1-977-MA33AFE
Fax A 617-727-7749
Revised 11-22a16 www.m=.gov/dies
1 v WN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PI:E4SE PRMT.
job Location:-
Number
Owner of Property: __S
SSd�C Qr.
Street
Village
Construction Supervisor. d r+ U C S -07/ S 7C d'a7- ysF-gos s
Name License No. Phone No
Address: - / %L Q r r %Z tJ l�►'1 t, •, t lr� c �� + jW * 0.L v y
Licensed Designee:
(If other than Supervisor) Name
• License No.
2.15 Responsibility of each license holder.
2415.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth. even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shalI willfullyviolate subsections 2.15.1.2.15.2 or 2.15.3 or any other section of these
rules and by regulations
and any procedures, as amended, shall be subject to revocation or suspension of
licensethe board-
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration. repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions. _
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes No (a
If you have checked UZ please indicate the type coverage by checking the appropriate ox.
iate b
A Ilability insurance policy � Other type of Indemnity ❑ Bond ID
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass General laws, and that my signature on this permit application waives Ibis requirement
Check one:
( Signature of owner or Owners Agent Chwer Q Agent Q
Signature: Building Official Approval:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, NIA 02664
508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.GL Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 77 of S ah t arc e. e
Work Address
Is to be disposed of at the following location: 0 v e Ss ti (O, c n s.,;
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, SecAn 150A.
of Application
Permit No.
L le'.- / -
Date
P TOWN OF YARMOUTH
Building Department
Town Hall
Yarmouth, MA 02664
(508)398.2231 ext.1261
BUILDING PERMIT,
TRANSMITTAL
Temp Permit No.: T-14-255
Applicant Name: RobertFasano
Applicant Phone: 5084988055
Building Location: 0277 SOUTH SHORE DR
Owner's Name: Surf and Sand Motel , „ pil/p/
Owner's Addres P.O. Box 1282
South Yarmouth MA 02664
Owner's Telephone:
*kVA=k111/d9l-l'E
(OFFICE USE ONLY
Recorded By.
IC
Permit Fee:
$0.00
Deposit Rec:
$25.00
Payment Type:
Check ChkNo.: 163
Net Owed:
($25.00)
Application Date: 1/28/2014
Issue Date:
Expiration Date
Comments: Map/Lot: 026.127
Interior renovations to rooms 104, 105, 204, 205-
220
1. WATER DEPARTMENT:
DATE:
N/A:
2. ENGINEERING DEPARTMENT:
DATE:
N/A:
3. CONSERVATION:
DATE:
N/A:
4. HEALTH DEPARTMENT:
DATE:
N/A:
5. BUILDING DEPARTMENT:
DATE:
N/A:
6. FIRE DEPARTMENT:
DATE:
N/A:
RECEIPT OF COPY:
SIGNATURE OF APPLICANT:
DATE:
Date Printed: 2/6/2014
at40-gk TOWN OF YARMOUTH
z " I c HEALTH DEPARTMENT
0 . _/ T
�. _� \ PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: ail gv v f 1 shore Qn v e
r n 1 1—G SG
"/fyou would like e-mail notification ofsign off, please provide e-mail address:
Tel. No.: 3vF-- 5/S F if as
Filed: / P?.6-/q
Owner Name:
Ja n
car-y r i. 0 a, o v e. rn n 1
Owner Address:_P
O,
(310)1 12 Fa .90 "a'- n" a L/f li
Owner Tel. No.: 6-oF- 3P 9-- S S-S
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY:
PLEASE NOTE
COMMENTS/CONDITIONS:
TE: 1 /�— &l
MGL AND f to iE
TOWN OF YAWOUTH
1' Nt REVIRVEU tOF; CODF COMPLIANCE.
j ERRORS OR OMMISS@NS OO NOT REuf
THE APPLir,ANI rgliM THEWPONSIBIL
OF OAS Puns CONI)p I/WCE
\ ° DATE..1��
r
INSPECTOR
YARMOUTH FIRE & RESCUE
Commercial Building Permit Sign Off
Project Name Surf and Sand Address 277 South Shore
Dr
Contact Name Robert Fasano Phone 508498-
8055
Y NO NA Subject Regulation
E
S
x
Access for Fire Apparatus
527 CMR 25.02
x
Building Numbers
MGL Chapter 148 sec 59
x
*Flammable gas/liquid storage
527 CMR 14.03
x
Fire Lanes
527 CMR 10.03(10)
x
*Service Stations
527 CMR 5 & 9
x
Wazardous Materials Storage
527 CMR 25.08
x
*tiitehen Exhaust Systems
780 CMR, 527 CMR 10.03(8)
x
Extinguishers
527 CMR 10.02, Chapter 148 sec 28
x
*Fire Alarm Systenis/CO detection
780 CMR, Chapter 148, 527 CMR 24,CMR 31
x
*LPG Storage
Chapter 148 sec 9,10,28 & 527 CMR 6
x
Pesticide Storage
527 CMR 37
x
*Sprinkler Systems
780 CMR & Chapter 148 sec 26 A -I
x
Storage inside/outside Buildings
527 CMR 10.03(5)
x
*Upholstery
527 CMR 29
x
*Trash Containers
527 CMR 10.04 & 34
x
Any Hazard to the Public
Chapter 148 sec 28
x
*Curtains, Draperies, Blinds
527 CMR 21
Description of planned project/other requirements: Interior renovations five rooms motel
* YFD permit required -de pendiu of occupancy and submittal
Plan Reviewed By: Date:/i�{1y
Copy for Applicant 0 C py to Building Department 0 Copy to Fire Prevention 0
�,i ODIC SatCt�
3ca !o ,o Zees .'a;, is and Standards
CS-071576
- 1 l
ROBERT P FASANOL'"�..
12 BIRD RD
MANSFIELD MA 02048
J�,��f� C.[OrallOa
07/18/2015
Unrestricted - Buildings of any use group which
contain less than 35,000 cubic feet (991M) of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS ticensing information visit: www.Mass.Gov/DPS
- ., '/IrY:r.ni.runvrrl/Ir �-/Iu:rirlrur•//.
Orrice of Consumer Affairs & Busihess Regulation
-'—�'HOMEIMPROVEMENT CONTRACTOR
r _ ,tegistntion: 126577 Type:
Explratlon: 6R22014 Individual
`ter. •
ROBERT P. FASANO
ROBERT FASANO
12 BIRD RD
MANSFIELD, MA 02048 Undersecretary
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
G
Not valid without signature
January 22, 2014
To Whom it May Concern:
I have hired Robert Fasano to do the construction work at the Surf & Sand Motel, located at
277 South Shore Drive, South Yarmouth, MA.
Best Regards,
Sandra M DiGiovanni
Manager
/os-
ao y
�o�/ - •�o-�a
r
REVIEWED FOR EUiLD NG AND ZONING CODE CCh1?LI-
ANCE. ERRORS OR 0%1P.tiSSiONS DO NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILITY OF "AS BUILD
COMPLIANCE.
DATE: 02 —20--/ j
Set ndrat 01(i10vannr,
,277 .Soo-�; 5;cr'e Drr-
vcirlmvU4') r m,4 o,�66 7
BUILDING OFFICIAL
FILE COPY
McKENDE
ENGINEERING
1279 Millstone Road
Brewster, MA 02631
t 774.353.2144
f 774.353.2142
www.mckengineers.com
14 February 2014
Mr. Mark Grylls
Building Commissioner
Town of Yarmouth
1146 Route 28
South Yarmouth MA 02664
RECEIVED
FEB 19 2014
BUILDING DEPARTMENT
RE: Structural Inspection Surf and Sand Beach Motel, 277 South Shore Drive, South
Yarmouth, MA
Dear Mr. Grylls,
McKenzie Engineering Consultants, Inc was retained by Bob Fasano, the contractor for
the project at the Surf and Sand Beach Motel to complete a structural inspection during
renovations on February 13, 2014.
Speaking with Bob Fasano, the representing contractor and observing the scope of the
project, given the past history of approval of renovations, and the limited impact of the
renovations, there are no concerns regarding the structure. Site inspection revealed no
significant degradation of the components. It is our opinion that the structure is sound
and that the planned renovations will not impact structure.
If there are any questions on this matter, feel free to contact me at any time.
cc. Bob Wolaszek, Project Contractor
Sincerely,
.� No.350G8
kA. Me E. �o 4R.
Pres., McKettz> t' it ' nsultants, Inc.
of r TOWN OF YARMOUTH Building Department BUILDING
(508) 398-2231 ext.1261
PERMIT NO SB-13-1149 PERMIT
M ISSUE DATE ;--314/2013_ - ; PROPOSED USE ;
APPLICANT 'Hapue Plumbing 8 Heating - - - - - - - - - - - JOB WEATHER CARD
-------------------------
PERMIT TO ; MiscJshsat metal ;
AT (LOCATION) 10277SOUTH SHORE DR ZONING DISTRIC R-25 Bldg. Type: Commerolal
SUBDIVISION MAP LOT BLOCK 1026.127 BUILDING IS TO BE: CONST TYPE USE GROUP =
LOT SIZE
CONTRACTOR
vent exhaust tans In bathrooms
REMARKS
AREA (SO FT) EST COST ($ $7,000.00 PERMIT FEE ($) $50.00
OWNER IDIGIOVANNI, SILVIO V BUILDING DEPT BY
ADDRESS 0277 SOUTH SHORE DR
South Yarmouth I MA 102664
LICENSE 11569
(Monroe, David
62 New Boston Road
Dennis Me 02638
5083649480
PHONE 15083989556 77-71
INSPECTION RECORD FIELD COPY
Date Note Progress - Corrections and Remarks Inspector
o� r TOWN OF YARMOUTH Building Department BUILDING
(508) 398-2231 ext.1261
PERMIT NO � FB-13-1079 � - ; PERMIT
..:.:-1079 .
r• ISSUE DATE ; _ 2.12/2013 _ ; PROPOSED USE ;
APPLICANT Douglas Snow ------------------ JOB WEATHER CARD
.
PERMIT TO Alterations
AT (LOCATION) 10277SOUTH SHORE DR ZONING DISTRIC R-25 Bldg. Type: Commercial
SUBDIVISION MAP LOT BLOCK 1026.127 BUILDING IS TO BE: CONST TYPE USE GROUP
LOT SIZE II
CONTRACTOR
LICENSE 069399
Snow, Douglas
971 Main Street
Waltham MA 02451
7818934548
replace 73 extedor entry doors UP
REMARKS
AREA (SO FT) EST COST ($ $115,500.00 PERMIT FEE ($) $200.00
OWNER IDIGIOVANNI. SILVIO V BUILDING DEPT BY
ADDRESS 117 Neptune Lane
South Yarmouth 102664
PHONE 6177999199
INSPECTION RECORD FIELD COPY
Date Note Proaress - Corrections and Remarks Insoector
2c-)—/
OF r
TOWN OF YARMOUTH
Building Department
BUILDING
'�-
(508) 398-2231 ext.1261
PERMIT NO FB-13-1055 ,
PERMIT
ISSUE DATE ; _ _2/4/2013. _ ;
PROPOSED USE ; _ _
_ ..
APPLICANT .Robert Fasano
•"""""""""""''
JOB WEATHER CARD
PERMITTO Alterations
AT (LOCATION)
ZONING DISTRIC R-25
Bldg. Type: Commercial
10277SOUTH SHORE DR
SUBDIVISION MAP LOT BLOCK 1026.127
BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-1
LOT SIZE
CONTRACTOR
permit transfer - refer to B-12.1487 -Interior renovations to rooms 110, 201 and 202, new gp
he
REMARKS and file floors as per plans dated 5116/12.
AREA (SO FT) EST COST ($ $15,000.00 PERMIT FEE ($) $35.00
OWNER IDIGIOVANNI, SILVIO V BUILDING DEPT BY
ADDRESS 49 Glenn Road
Belmont MA
LICENSE 71576
IFasano, Robert
12 Bird Road
Mansfield MA 02048
5OM88055
PHONE 16177999199
INSPECTION RECORD FIELD COPY
Date Note Progress - Corrections and Remafks Inspector
=>V azaz --#— //V - 20/ — 2.6 Z ,
a
of r TOWN OF YARMOUTH Building Department BUILDING
" (508) 398-2231 ext.1261
.. -- --,
PERMIT NO B-12-1487- . ; PERMIT
ISSUE DATE 5/21/2012 _ ; PROPOSED USE ;.
Kie'r' """"" JOB WEATHER CARD
APPLICANT Joseph Butler
PERMIT TO Alterations
AT (LOCATION) 0277SOUTH SHORE DR ZONING DISTRIC R-25
SUBDIVISION MAP LOT BLOCK 1026.127 BUILDING IS TO BE: CONST I
LOT SIZE
Bldg. Type: Commercial
'E 5-B USE GROUP R-1
Interior renovations to rooms 110, 201 and 202 - new kitchens, baths and Via floors as per plans datefd
REMARKS 05116/12.
AREA (SO FT) EST COST ($ $15,000.00 PERMIT FEE ($) $270.00
OWNER IDIGIOVANNI, SILVIO V BUILDING DEPT BY
ADDRESS 140 Glenn Road
CONTRACTOR
LICENSE 071486
Butler, Joseph
POB 306
East Harwich MA 02645
5087604949
Belmont MA I PHONE 16177999199
INSPECTION RECORD
FIELD COPY
Date
Note Progress - Corrections and Remarks
Inspector
.1- z - 42
I-Ai5?1xu 0/- �u n
o' ►
TOWN OF YARMOUTH
Building Department
BUILDING
+
(508) 398-2231 ext.1261
PERMIT NO FB-13-1081-
- - 08 .
.; PERMIT
a
ISSUE DATE ; • 2/13/2013 - ;
.
PROPOSED USE ..........
APPLICANT ----- •-------------- '
.... Fasano
JOB WEATHER CARD
PERMIT TO Alterations
AT (LOCATION)
ZONING DISTRIC R-25
Bldg. Type: lCommercial
10277SOUTH SHORE DR
SUBDIVISION MAP LOT BLOCK 026.127
BUILDING IS TO BE: CONST TYPE USE GROUP=
LOT SIZE
i I
remodel existing kitchen & bathroom In units 101, 162, 163, 203, 118, 2Y8 as per plans date 2/06 .
REMARKS up
AREA (SO FT) EST COST ($ $12,000.00 PERMIT FEE
OWNER IDIGIOVANNI, SILVIO V BUILDING DEPT BY
ADDRESS P O Box 1282
CONTRACTOR
LICENSE 71576
IFasano, Robert
12 Bird Road
Mansfiled MA 02048
5084968055
South Yarmouth MA 02SU PHONE 5083989556
INSPECTION RECORD
FIELD COPY
Date
Note Progress - Corrections and Remarks
Inspector
2 -Z — 3
ok AS
a-
Re -Inspections or Additional Fees
Electrical
Re -Inspection $80.00
Additional Fee T.B.D.
RECEIVED
ay
FEB 1q 2014
Re -Activation of old permit $50.00 (Residential)
$80.00 (Commercial)
Date: �- �/ 9 /i L/
Address: Q 77 9u-.t4 S-_� 76
Issued to: 14J IJJJ-1.4'L
Reason for Fee:
Permit Number: Fi3 -f3 - /cF- J
Amount received: e /-To-0-,7)
Cash: Check & Check Number: Y6Y3
Commonwealth of Massachusetts
Sheet Metal Permit
Date: eZ (`� Permit # "/V' goo-)
Estimated Job Cost: $ SO d. Permit Fee: $
Plans Submitted: YES NO A
Business License # q 9 V q
Business Information:
Name: �W x, e I b � . t4j
Street: b N RoSVa,- JRA
City/Town: (AA 0,w l
Plans Reviewed: YES NO
Applicant License #
Property Owner / Job Location Information:
Name: Sur t qv,.A
Street:O!nSattikA--. 5kff{ 0-r-
City/Town: 5_ �!j u o! 4,� M A
Telephone: (Ta Y) 3 61 ^ `1 i f(U Telephone:
Photo I.D. required / Copy of Photo I.D. attached: YES
J-1 / M-1-unrestricted license
NO
srfrwsm
J-2 / M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less
Residential: 1-2 family
Multi -family
Condo / Townhouses
Other L
Commercial: Office
Retail
Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ftover 10,000 sq. ft. Number of Stories: I
Sheet metal work to be completed: New Work:
HVAC Metal Watershed Roofing _
Metal Chimney / Vents
Provide detailed: description of work to be done:
Renovation:
Kitchen Exhaust System
Air Balancing
1 •0%
� 1
ESS
TEST REQUIRED
Suction 493.2 of tite Energy Gode requites eak testing
of ducts installed in Non Conditioned Spaces. Two options
i(g fiD,,!r4r& Prct.rrncfrcrtirn Trst nr Rough In Test.
R ri Ey E d An Approval Certification is required from an authorized
leslina agency before the Building Dept. will Issue a
Certificate of Occupancy or final approval of the work.
INSURANCE COVERAGE:
I haV8 0 current liability insurance policy or its equivalent which meets the requirements of M.G.L Ch.112 Yes Limo ❑
If you have checked Yes. Indicate the type of coverage by checking the appropriate box below:
A liability Insurance policy S5 Other type of indemnity ❑ Bond ❑
OWNEk'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the
Masgdehusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ - Agent ❑
Signature of Owner or Owner's Agent
By cht6king this boxg. I hereby certify that all of the details and Information I have submitted (or entered) regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this application will be
In eomoliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. -- - - - -
By
Date
Duct inspection required prior to Insulation installation: YES NO
Proeress Inspections
Comments
Final Inspection
Date Comments
❑ Master
Title
❑ Master -Restricted
Cityll own
❑Joumeyperson
Permit #
❑Joumeyperson-Restricted
Fee 3 ._
Inspe6t6r Signature of Permit Approval
Signature of Licensee
License Number.
Check at www.mass.00v/dal
Compensad��
Name
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Invesdgadons
600 Washington Street
Boston, MA 02111
wW.mass gov/dia
Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
'-"'i itate/Zip: ID-f- Z 5ty� �} p� 13 F Dt.
Are you as employer? Check the appropriate box: 4Yuc
1 ❑ I
'ao3/aI—q%(Yo
am a employer with 4. 0 I am a general contractor and I
employees (full and/or part-dme).� have hired the sub-conttacton
2.
0 I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp, insurance
required:]
0
3.I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
3a. ❑ I am a homeowner acting at a
general contractor (refer to #4)
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp, insurance.t
5• We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152. § 1(4), and we have no
employees. [No workers'
comp, insurance required,]
;Any C0wopplQ t that checks box a mart also fin out the section below showing their wod=z. compcn$UW
t Homeowner who submit this affidavit indicating they am doing all work and then him outside 0o� information.
tCoattactors that check this box must attached an sddiuoud shod showm COO � submit a new atMavit indi adn emPioyees. If the nib conmactor have [the name of the nrb.coonadoti and state w [such
coTtoyees, they must Provide their worker' comp, policy number. whether a not those entities have
,ran apt tatployer that is providing workers' compensation insurance f or infornmdon, my employes. Below Jr rhs policy and job site
Insurance Company Name:_
Type of project (required):
6. ❑ New construction
7. 0 Remodeling
8. 0 Demolition
9. 0 Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address.
Attach a copy of the workers' compensatioCity/State/Zip:
n policy declaration page (showing the policy number and ez{plratloo date).
Failure to secure °overage as requ11ed under Section 25A of MGL c. 152 can lead to the imposition of criminal
fine up to $1,500.00 and/or one-year imprisonment. as well as civil penalties in the forth of a STOP WORK ORDER and a fine
Of up to 5250.00 a den a penalties of i
Y against insurance
violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
- -- ..-• ,F c4r"JJY rrnwsr ins paint and penakla of perlury'thot the lnformadon !s provldtd above lrrrt
Sionahtm. �l 7 Uti andeonva
-q%i A
Of j clat use only. Do not writs in this area, to lot completed by city or town offlcial
City or Town:
Z f
Issuing Authors (circle Permiuucense #
I. Board of Health2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person:
Phone #:
Information and Instructions
wuxl � mmpeasatian for their unnplo�
Leas chapter 132 requires ell �PbY� pia the savtce of another uada any contract of hit%
Messuh to thi tft el is defined u »•eel► pam
Ptasuasot to this stattate, as aspfsyr�s
express a implied, oral a written.
esso WiM orporatiat a other laid mtityt a any two or more
An ssm 1gff is de6aed a "m isdiridnal. Pam d, le � o[a deaeeed emQloye� a the
in a joint mterpriae. end iaclndiag the
of dw fmving copg� at other ]egsl mtltl►. tm&,, . og r dm oc ea' H ofthia
receim of ttvstu @ of as iadMdoO Pam is thas "qmewnm and who reside theteart, a tltm °�°t rach elling the _
awoa of a dwelling liooss having
nP� Penn to do construction a rgbe deems to be an emP�"
dwdlkg bonne of another �� sts8 baauss of loch emploY�m
or on the ponade a building
" a" at Ieca! 0c d" army ASA wtthWd the "Isla" K
Melt. chaQetr 132. !u«� a1'OJtaedthd at b eesetrsd bdldhip V the amoeiwalth for to
renewal of a lice ae P t' °fib wick the tomms" emrtrs P math•~
eppltnat wr ham am prelee� s P eon wealth net nay oIN"f is Political mbamdom �l
enter into m mGL,con& chapter s p l�M of public work until aeeeptabb evideau;e of tomplisms with the inwcmce
e� irecuircIncum oaf contract dot the pafbstastre ha
of this to the eoct meting 212lamity-thischapter ve bees pseaenttd
Appuesw afIIdavlt compktah►v b)► cheddai bona that bothat apply to Yong sitnatias and. it
plan till out the woalm , cuamP�� es(e) do" with their catlffcaee(m) of
ee oemey, supply ems) °'m°(�)' mddtesaLWaq () and Ph00a Partnerships (LLP) with no amPlonp other d m the
at Lhubd
dURVfL
InaurancL Limited Liability Campeo lot required� eaery(�wotfre>, Boras • if an LLC of LLP dam bare
�P c °tms m�edBe advised that this a@fdmritt map be submitted to the Depectment of I>=el
Aaidentb[ dos of iaswmem coraagR Alm be mb alp and date thm Ib aatl3darit shod d
be reed to the city a tows that the appiieados for the permit err tieumse f onag rmpd to � a� bra'
Rlym-6 the law at if et, reRaieed should eater theft
Iodnstsid Aeeiden�m
.. w the ao:abet listed beiow 3df4wjmdcompanies
enr�ead:as PoHCYI P mp can the�... �t..�
Clty err?ata►s ODfefate
place be rue that the atBdavtt {a coa>plete and prbsoed legibly. '[bm Depet<mmt hogt�� a'P" Ce at thm halloo
of the all &mk fm Yon+ to fm out is the avant the O hit otlnvesmdaam hen to coarse! Yet rig thm appl""k
pleat be save to fib m ° which veld hm nsed sus need Only =be * c �� �
that moat sstbmit n applications in my fires Year
taitirmdios (if accessary) and unda "Yoh Stan Addease" she aPPliemt should writ "ell ioeatbam is (city or
Pow o[ the all3dtris that has hays otfleiallp aged at minced by the city a tows may be provided b the
town}" A eopf i rdid athat hat sa os tW fbr tiamis pa ndW a lk°maa A new affidavit snot be tW ad each
applisxnt r PsO°f a eitism is obteidng a limn at pan* sat mbded to' my bttrfoess a eommereW vest
(�. wbae a home owmr said Pates to lees this siiidariL
a dof lieanam or peamit to bunt leaves ate.) is NOT requited g
!-Hm
would lib to thank you in adruma for yang eooperetios sad should you have any tsestionr.
'Tits Otiiem of lntresdptions
piease do not hesitate to give as a all.
VA Depa meets address, telephoss and fa number.
The Commonwealth of MLW=h i,etb ,
Depeftcd of Industrial Accidents
ONee of hmeoptiess
600 wamhingtott street
Boston. MA 02111 :
Tel.11617•721-4900 ext 406 of 1-VI-MASSAFB
Fax 11617-727-77d9
Revised 11-22416 www.m=s.Vv/d1a
Commonwealth ofMassaehusetts
— Department of Fire Services
�r l BOARD OF FIRE PREVENTION REGULATIONS
Official Permit No. IL4--(G2
Occupancy and Fee Checked
[Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 6/27/13
City or Town of: YARMOUTH To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
(Street & Number) 277 SOUTH SHORE DRIVE, SOUTH YARMOUTH, MA 02664
or Tenant SURF & SAND
Telephone No. 508.398.3700
.'s Address
permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
of Building House Utility Authorization No.
Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
vice Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: INSTALL LOW VOLTAGE CAMERA SYSTEM.
Completion of the following table may be waived by the Inspector o Wres.
No. of Recessed Luminaires
No. of Cei6 Paddle
P (Paddle) Fans -Sus .
o. n ota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
ove n-
Swimming Pool rnd. Elrnd. ❑
o. o mergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. o eteng D an
Initiating Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Alerting Devices
No. of Waste Disposers
p
eat ump
Totals:
Number
ons
o. o cif -Contained
Detect ion/Alertin g Devices
No. of Dishwashers
S ace/Area Heating KW
P g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
�'
Heating Appliances KW
ecu 'ystems:
Noo.. of Devices or Equivalent
o. o atcr KW
Heaters
o. o o. o
Signs Ballasts
Data Wiring:
No. or Devices or E uivalent
No. H dromassa a Bathtubs
Y g
No. of Motors Total HP
Telecommunications inn
No. of Devices or F, uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of lrires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penattles of perjury•, that the Information on this application is true and complete.
FIRM NAME: Alarm New England LIC. NO.: 11975-A
Licensee: William Allison Signature LIC. NO.: 11975-A
(Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: SOR-394-8900
Address: 22 White's Path, South Yarmouth, MA 02664 Alt. Tel. No.: 800 R72 9823
*Per M.G.L. c. 147, s 57-61, security work requires Department of Public Safety "S" License: LIC. NO.: SSCO 001348
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's aeent.
Owner/Agent PERMIT FEE: S IIS.00
SignaturetoreTelephone No.
1 Nil
•�
e
11
IJ
r.
rf(8 Zfa3
Official Use Only
Permit No.
BOARD OF FIRE PREVENTION REGULATIONS 71cy
and Foe Checked
. ' Cave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 27 CMR 12.00
�EASEPRINTININKOR ME AU INFORMA T10A9 Date: 3 1q%1 3
City or Tony of: YARMOUTH To the Inspecto of Wires:
this application the prtdersigned gives notice of his or her intention to.Eerform the electrical work described below.
" in (Street & Num" "�' 1
'orTenant S
S Address
Ito), to 2. 1031
(. mmsonweaR of It/amaciar ujb
�cparimanE o��lr• Jcrviu!
Telephone No.
Permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
of Building Utility Authorization No.
7Etisting Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and
` ,Nature of Proposed Electrical Work:
_(0 1344 to o"C
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No, of Meters
No. of Recessed Luminaires
corn .court ur lne ouomn
No. of CdL-Susp. (Paddle) Fans
ranee may be waived try the Inspector of Wirer.
o. of otal
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires b
Swimming Pool Above ❑ n- ❑
o. o mergency g twg
ernd. amid.
Battery Units
No, of Receptacle Outlets b
No. of Oil Burners
FIRE ALARMS
No. of Zones
No, of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No of Air Cond. Tons
No. of Alerting Devices
No, of Waste Disposers
Heat ump
umber
ors
o. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p
Local Q Mu ci al
❑ Other
'
Connection
No. of Dryers
Heating Appliances KW
Security Systems:'
No. Devices
o. o aces KW
Heaters
o. o o. o
of or Equivalent
Data Wiring:
Signs Ballasts
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications trfno:
No. of Devices or Equivalent
OTHER:
Estimated Value2o.. v "utrcq or as reguirea by the inspector of Wires.
Elrotrical Work 0 (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. '✓> (�,
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless' 1
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I cer*, under the pains and penaltles of erjury, that the information on this application is true and complete
FIRM NAME: W t 1 �c lu S Z LIC.
Licensee: W ` G S Signature LIC. NO.:
(ljapplicable enter "exempt" the tense number lin_e,) Bus. Tel. No.
Address. 9 (� rTl lo�,t�a ��rL+ Alt. Tel. No.:
*Per M.G.L. c. 147, s. -61, secunty ork requires Department of Public Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner ❑ owner's agent_
Owner/Agent
Signature Telephone No. PERMIT FEE: $
916 -?6019?66
BUILDING PERMIT APPLICATION
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF,
OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
To%vn of'larniouth Building Deparinient
1146 Route 28 • tiarnuruth, ,N[A 0266 -1-192
Tel: 508-398-2231 eel~ 1261 Fax 508-398-0836
Office Use Only planning Board Information Assessors Department Information:
a PI a tyors pe Map to
Permit Fee $�S� of inert /a
15—
R cording Date New
Permit N0,Deposit Rec'd. $ () Date Plan No. 1.4 Property Dimensions:
Net Due $ -36 Other lot Area IV) Frontage (it) Lot Coverage
This Secdon for Office Use Only
Building Permit Number.
Date Issued:
Certificate of Occupancy
Signature:
Building Official Date
is Is not required
Section 1 - Site Information
1.1 Property Addresm 1.2 Zoning Information:
27 7 Soy- � 940- Dr,. 13-AS
�S� 4 r- "ocp 4- h Pn 4- Zoning District Proposed Use
1.3 Building Setbacks (it)
Front Yard Side Yards Rear Yard
Required I Provided Required I Provided Required I Provided
�1.4 Water Supply (111.O.L. c. 40. S 54) 1.5 Flood Zone Information: Comments:
Public Private Zone: BFE
Section 2 - Property Ownershi Authorized Agent
2.1 Owner of Record: A/ 9 G /c n el 1
Sr/✓/o (/ 171Sfol/4nnl �ooT" r EP
Name (print) Mailing Address: 13y
Signature Telephone Telephone
2.2 Authorized Agent:
�Sr.�f— de4C D l c 1 2 n
Na ( Int) Mailing Address:
S nature Telephone Fax
Section 3 - Construction Services
3.1 licensed Construction Supervison Not Applicable
fJ i rd irk Im 4'j S ., t/y/ M�4 0`2 0 q dense Number
Ad
2 C Da
Expiration Date
1_�
Signature Telephone '7 —,/ S7 ^.13
13
a■
1 of 4 OVER
3.2 Registered Home Improvement Contractor.
Com/(ny/ Nam•
{�
r �GS G d
❑ Not Applicable
Registration Number
7
AddressD n �i /. !
� � lam' ,�.-�t�� S �l � �S OS.S
E fratiort Cato
o
Expiration
G - ,2 2
Signature Telephone
Section 4 - Workers' Compensation Insurance Affidavit (MAL c. 152 S 25C (6)
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached Yes .......... No ..........
Section 5 - Professional Design and Construction Services - for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116 (containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect:
Not Applicable ❑
Name (Reyistrontlt
Registration Number
Address
Signature Telephone
Expiration Date
Section 5.2 Registered Professional En ineer(s)
Name
Area of Responsibility
Address
Signature Telephone 1
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Oats
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration oats
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Section 5.3 General Contractor
Not Applicable ❑
Company Name
Person Responsible Jor Construct n
� a0 u S rc ✓ vd0�-/�
Addre
S' nature Telephone
2of4
SECTION 10b OWNER/AUTHOAIZED ,GENT DECLARATION -
I, R oS e� •% P /C95et a G , as Owner/Authorized Agent
hereby declare that the statements and information on the forgoing application are true and acurate, to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Print Nam
/ /�es-3v./�
Sig ature of Owner Age t Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be
completed by permit applicant
1. Building
2 Electrical
3. Plumbing / Gas
4. Mechanical (HVAC) -
5. Fire Protection
B.Total -(1+2+3+4+5) /S . 0 0 0 - JO
7. Total Square Fl. (Mr m. sncnxw t Aftmm)
Check Below
❑ Conservation -Commission Fling
(if applicable)
❑ Old Kings Highway S Historical
Commission approval
(if applicable)
4of4
P
Section 6 - Description of ProDosed Work (check all anolicablel
New Construction ❑
I (for multiple family only) No. of Bedrooms
(for multiple family only) No. of Bathrooms
Existing Bldg. ❑
I Repair(s) ❑
I Alterations
Addition ❑
'
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work:
l e/-fu�- a'lo Va-7-7o-I S v on
/(, 0 �D
Section 7 - Use Group and Construction Type
Building Use Group (Check as applicapable)
Construction Type
A ASSEMBLY
❑ A•1 ❑ A-2
A-4 ❑ A•5
❑
❑
A-3 ❑
1A ❑
18 ❑
8 BUSINESS
❑
2A ❑
28 ❑
2C ❑
E EDUCATIONAL
❑
F FACTORY
❑ F•1 ❑ F-2 ❑
H HIGH HAZARD
❑
3A ❑
38 ❑
1 INSTITUTIONAL
❑ I.1 ❑ 1-2 ❑
1.3 ❑
M MERCHANTILE
❑
4 ❑
R RESIDENTIAL
❑ R•1 ['f R-2
❑
R-3 ❑
5A ❑
58
S STORAGE
❑ S-1 ❑ S-2 ❑
U UTILITY
❑
I
SPECIFY:
SPECIFY:
SPECIFY:
M MIXED USE
❑
S SPECIALUSE
❑
Complete this section If existing building undergoing renovations, additions and/or change Iri use.
Existing Use Group:
Existing Hazard Index 780 CMR 34
Oroposed Use Group:
Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area
Building Area
Existing (if applicable)
Proposed
Number of Doors or stories
Floor Area per Floor (st)
Total Area All Floors (sf)
Total Height (ft)
Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes .......... No ..........
SECTION 10a OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property,
hereby authorize Fajc4' 6 to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
3 30 -ice
Date
M
3of 4
OVER
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Bostot4 MA 02111
-www.massgov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricIans/Plumbers
Name
2 13,, a
/ I"oScn h 0
City/State/Zip: i''31 vasZ. /4 v> oy Phone #: 23 9- F 32 5
Are you an employer? Check the appropriate box:
❑ I am a g
I am a employer with 4. 'general contractor and I Type of project (required):
I. ❑
CRIP yees (full and/or part-time).' have hired the sub -contractors 6. ❑New construction
2. am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required] t
3a ❑ I am a homeowner acting as a
general contractor (refer to #4)
listed on the attached sheet.
These sub -contractors have
employees and have workers'
Comp. insurance t
5. ❑ We are a corporation and its
officers have exercised their .
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. (No workers'
comp. insurance reauired.l
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
l 1-0 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
'Any applicant that checks box # I must also fill out the section below showing then• workers' compeasatiod�o6cy information
t Homeowners who submit this affidavit indicating they are doing all wort and then hire outside contractors must
tContnsctors that check this box must attached an additional sheet showing the fume of the subcontractors
and asubmit a new affidavit indicating such
employeeal if the sub-eonnacurs have employees, they must provide their workers' comp. policy number. tau whether or not those entities have
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. M Expiration Date:
Job Site Address: I 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 fore
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby eeltlf 'der the al ' a enalties of perjury that the information provided above is true and correct
,,-30-/ �;?,
Phone #: ,S—i g- 3 3 9 — F'3 2
Of f ieial use only. Do not write in this area, to be completed by city or town official
CIty or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone #'
Information and Instructions.
MassaclnLw ta General Um cbapter 132 requires all employ!$ to Provide worken' compensation roc their employes.
Pursuant to this statute, an explipte is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written.»
» auocntion, corporation or other legal entity, or any two a more
An saspli�s► b defined a an individual, pastaershia , a the
of the foregoing engaged in a joint enterprise, sad ineheding the legal repra�ives of a deceased empkeyts
receive at trustee of as Individual, partnership, association or other legal entity, employing umPbyem However the
owner of a dwelling bones having not more than three apartments and who resides therein, or the Occupant of the
dwelling boast of another who employs persona to do maintenance, construction or repair work or such dwelling house
of an the grounds or building appurteasnt thereto sball not because of such employment be deemed to be an employes:"
MGL chapter 132, 42JC(6) also states that "every state er lees! Heeuain agency all the eommoM than. am or
renewal of a Beene w permit is operate s badness or is construct buddlaga
oed acceptable evideme of eompUana with dw htsm" t coven" regairf
aPP�� ly, G chi of its Political subdivisions shall
Additionally, MGL chapter 132, �23C('7) states "Neither the commonwealth nor any
enter into any contract for the performance of Public work until acceptable evidence of cOmplianee with the ins rsnce
reoueiremecta of this chapter have been presented to the contracting autbocitl►."
Applicants .
Please ins out tit workers, comps Mtian affidavit eomptetsy, by checking the boxes that apply to your sitttatien sad, if
necessary, sappy suboontraetos(s) name01 eddress(es) and plow number(s) along with there catifieste(s) of
ins mwL Limited tiability Companies (LLC) at Limited Liability Putnerships (LLP) with ao employees other than the
members or pu ban are not required toarmy workrml compensadon insuraaee. if anLLC or LLP does bays
employees, a policy is required. Be advised that Me affidavit maybe submitted to the Departmea! of Induatrisl
Aeoddeab fag confirmation of insurance coverage. Alt be sate to signand date the dWavIL The affidavit should
be returned to the city at town that dw sppUesdos for the permit of Been" is being requeruA nat theto obtain
met of
industrial re Accidents. Should you have any gmsdons retarding the taw or if you arequired
compensation polity, please can the Departmess at the number listed below. Self -inn i ed coa>Qeaies should eater their
self iawraaes license number on the sPPeoprL■te lice.
City or Town OMC1210
PIesse be sure that dw affidavit is complete and printed legibly. 'flee Department has provided a space at the bottom
of the "Bdavit fof you to fill out in the event the OfBcs of Investigations has to contact you regarding the aPPBCIUL
Please be sure totill in the Pun iWcense "'ante- which will ba used sa a refereuee number. Ian addiflM anaPp6cw t
that most submit muUipie permiVUcenae applications in any given yew, mad only submit am affidavit h dicstiag current
polky fatfl =do u (if necemmy) and under "lob Site Address" the applicant should write "ail locatione to (city or
town)." A copy of the $®davit that has been officially stamped or marked by the city at town may be provided to the
appUcant es proof tint a valid affidavit is ou file for Nturs permits or licenses A new alBdavit must be filled out each
yew. Where a hams owner or eid= is obtaining a Beene at permit not related to any business of commercial venders
(i.e. a dog license or permit to burn lean etc.) said person is NOT required to complete this and avit
The O nkg of Investigations would I&@ to thank you in advance for your cooperation and should you have any questionse
please do not hesitate to give us a call.
Ctrs Department's address. telephone ud fie number:
The Commonwealth of Massachusetts
Deptutment of Industrial Accidents
Offlee of Investlptloos
600 Washington street
Boston, MA 021 It
Tel. 11617-727.4900 ext 406 or 1-977-HtASSAFE
Fax a 617-727-7749
Revised 11-224)6 www.mass.gov/din
° R TOWN OF YARMOUTH
t�s-.-• BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT:
job Location:— ;t 77 sj.:j e pr. l�ur "op � S
Number Street Village
Owner of Property- V v
Construction Supervisor: (0-5e
Name
CS 7 /S7 G a F' 9 y y-- F0s-3'
icense No. Phone No.
Address: -/ 2 fled V .P I'1-1v-15/?te/J kw 0aog7-
Licensed Designee: / tOJe;
(If other than Supervisor) Name
SG.i D
2.15 Responsibility of each license holder.
License No.
7
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is, not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfullyviolate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities tinder the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes Ef- No ❑
If you have checked yo, please Ind' the type coverage by checking the appropriate box
A liability insurance policy . Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
of Owner or Ownees Agent
Owner a Agent 0
Signature: Building Official Approval:
. o� . TOWN OF YARMOUTH
BUILDING DEPARTMENT
C y 1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext.1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at ,Z 7 7 S 4o r e- Or.
Work Address
Is to be disposed of at the following location: _t.14 rinoa-��l Dv m p
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Application
Permit No.
y -30-/;L-
Date
�e t[O)IfIN01/rr/Mr�l� �/'dll�rur/rc�cla
Office of Consumer Affairs & Busi ess Regulattou
N _ OME IMPROVEMENT Type.
istration 126577
W""plratj..:
6/2212014 Individual
'i-
ROBERT P. FASANO„
ROBERT FASANO
12 BIRD RD g
MANSFIELD, MA 02048 " Undersecretary
*Massachusetts - Department of Public Safe*
Board of Building Regulations and Standards
Construction Supervisor License
License:, CS 71576
ROBERT P FASANO
12 BIRD RD
MANSFIELD, MA 02048
Conuui>sioner
Expiration: 7111/2013
Tr#: 18333
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer to: WWWMuLGovlDPS
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
1MNota
Suite 5170
B
t signature
/�\�
• i 1
LSurf & Sand
on Nantucket, Sound
oil I •• u • to 6
May 29, 2012
To Whom it May Concern:
As of today Joseph Butler is no longer the contractor at the Surf & Sand Beach Motel located on 277
South Shore Drive, South Yarmouth. The new contractor is Bob Fasano.
If you have any questions please feel free to contact me at 508-398-9556.
Thank you
Sincerely,
Sandra . DiGiovanni
General Manager
277 South Shore Drive
So. Yarmouth, W 02664
508-398-3700
o. r
TOWN OF YARMOUTH
Building Department
Town Hall
Yarmouth, MA 02664
(508) 398-2231 e41261
BUILDING PERMIT
TRANSMITTAL
Temp Permit No.: T-12-428
Applicant Name: Robert Fasano
Applicant Phone: 5084988055
Building Location: 0277 SOUTH SHORE DR
Owner's Name: DIGIOVANNI, SILVIO V
Owner's Addres 49 Glenn Road
Belmont MA
Owner's Telephone: (617) 799-9199
(OFFICE USE ONLY
Recorded By.
Ic
Permit Fee:
$35.00
Deposit Rec:
$0.00
Payment Type:
Check ChkNo.: 0
Net Owed:
$35.00
Application Date: 6/4/2012
Issue Date:
Expiration Date
Comments: Map/Lot: 026.127
permit transfer - refer to B-12-1487 - interior
renovations to rooms 110, 201 and 202, new
kitchens, baths and tile floors as per plans dated
5/16/12.
REVIEWED BY:
1. WATER DEPARTMENT:
DATE:
N/A:
2. ENGINEERING DEPARTMENT:
DATE:
N/A:
3. CONSERVATION:
DATE:
N/A:
4. HEALTH DEPARTMENT:
DATE:
N/A:
5. BUILDING DEPARTMENT:
DATE:
N/A:
6. FIRE DEPARTMENT:
DATE:
N/A:
COMMENTS:
RECEIPT OF COPY:
PLEASE NOTE
SIGNATURE OF APPLICANT:
DATE:
Date Printed: 6/7/2012
J
.OF.y,9R
N�TTACN[ [
BUILDING PERMIT APPLICATION
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF,
OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Totvu of'lannotith Building Depariment
114fi Route 28 • lannouth, ,NIA 02(iti-1-4492
Tel: 508.39&2231 eat, 1261 Fax 508-398-0836.,
Office Use Only Planning Board Information Assessors Department Information:
Permit II . '� to Trpe M�� to
Permit Fee orsement Date
ecording Date New
Deposit Rec'd. $`� , Date bJ an No. 1.4 Property sirions:
Net Due $ � � Lot Area (so Frontage (it) Lot Coverage
This Section for Office Use On
Buildinq Permit 614mber
Date Issued:
Certificate of Occupancy
Signature:
Building Official Date
is Is not required
Section 1 - Site Information
1.1 Property Addresss 1.2 Zoning Information:
��u M0U 4 i�1 /l— Zoning District Proposed Use
1.3 Building Setbacks (ft)
Front Yard Side Yards Rear Yana
Reouired I Provided Reouired I Provided Reouired I Provided
1.4 Water Suppty I&LO.L- c. 4M S S41 1.5 Flood Zone Information: Comments
Public Private Zone BFE:
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Records / .C7. 1
0 r t� Q
Sin n ri�� k ) ; I uy 'I n / So Uri M�.rw u f! 1 lyl ✓T
Name (print) Mating Address: n nn
-.3-0 6 3 9 7-- .S u u
Signature Telephone Telephone _
U rLIJ I I 1UIj
2.2 Authorized Agg�enC
1?0 /�i i %) (7 � � !Jr he) J j By UILD NGDEPT
Name ( nt) Mailing Address: rnNirJ re , wvlyloy
ignature Telephone
Section 3 - Construction Servicesi d
3.1 Licensed Construction Supervisor of Applicable
?oSV-. -r P rssC, 0 FEB 0 4 2013
BUILDING DEPT ense Number
Address CS w 7 6
� G7r 51q ,{ - yrs',)- Expiration Date
gnature Telephone - 3
1 of 4 OVER
3.2 Registered Home Improvement Contractor.
Co any Ham*
d #r 1`'CF s
Not Applicable ❑ -
Registration Nurnbe�
,
A es nn/ f r. i /Z , /Yl [� a s .r 1 G . , l ,m
j0 % - ,V 9 7 - F-OS- Y-
Expiration Date
G- -(91
gnature Telephone
Section 4 - Workers' Compensation Insurance Affidavit (MAL c.152 S 25C (6)
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached Yes ........ No ..........
Section 5 - Professional Design and Construction Services - for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116 (containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect
Not Applicable ❑
Name (Regfstrant)t
Registration Number
Address
Signature Telephone
Expiration Date
Section 5.2 Registered Professional Engineer(s)
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Dan
Name
Area of Responsiblflty
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibifity
Address
Signature Telephone
Registration Number
Expiration Date
Section 5.3 General Contractor
Not Applicable ❑
Company Name T
Pn ASS 17 D
Person Responsible for Constn ction /� L
oZ f n e.( a 17 S i((/ e.
Addy" (1 sr r - -f X - e Os 5—
Si ure Telephone
2of4
\action 6 - Description of Proposed Work (check all applicable)
New' Construction ❑ (tor multi
ple family only) No. 01 Bedrooms
(for multiple family only) No. of Bathrooms
Existing Bldg. ❑
I Repalr(s) ❑
1 Alterations Er
I Addition ❑
Accessory Bldg.
❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work:
/Tevnode- (3a,(- t%v»I
vr,IT.r
o/ d� l03
D 4/0 f=/�
Section 7 - Use Group and Construction Type
Building Use Group (Check as applicapable)
Construction Type
A ASSEMBLY
❑ A-t ❑
A-4 ❑
A-2 ❑
A•5 ❑
A•3 ❑
1A
1B
❑
❑
B BUSINESS
❑
2A
23
2C
❑
❑
❑
E EDUCATIONAL
❑
F FACTORY
❑ F-1 ❑ F•2 ❑
H HIGH HAZARD
❑
3A
3B
❑
❑
I INSTITUTIONAL
❑ I-1 Cl 1-2 ❑ 1-3 ❑
M MERCHANTILE
❑
4
❑
R RESIDENTIAL
❑ R-1 ❑
R-2 ❑
R-3 ❑
SA
5B
❑
❑
S STORAGE
❑ S-1 ❑ S-2 ❑
U UTILITY
❑
SPECIFY
SPECIFY.
SPECIFY:
M MIXED USE
❑
S SPECIAL USE
❑
Complete this. section if existing building undergoing.
renovations: additions and/or than a Iri use.
Existing Use Group:
Existing Hazard Index 780 CMR 34
1
1
Proposed Use Group:
Proposed Hazard Index 7B0 CMR 34
Section 8 Buildinq Helqht and Area
Building Area Existing (f applicable) Proposed
Number of Iloors or stories
include basement levels
Floor Area per Floor (sq
Total Area All Floors (sl)
Total Height (ft)
Section 9 - STRUCTURAL PEER REVIEW (780CMR 11011)
Independent Structural Engineering Structural Peer Review Required Yes .......... No ..........
SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property,
ere y au onze
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
3of4
Date
to act on
OVER
I
SECTION
N110b/OWNER/ AUTHORIZED AGENT DECLARATION
/-4S ci n f7 , as Owner Authorized Agent
hereby declare that the statements and information on the forgoing application are to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
c�S e •• � 4 Ci i1 b
Print am
lure of Owner/Agent Date
Section 11 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be
completed by permit applicant
1. Building
2 Electrical
3. Plumbing / Gas
4. MechanI al (HVAC)
5. Fire Protection
ILTotal .(1+2+3+4+5) % 0�
7. Total Square FL Itvnw O=m t aditm) ii D
Check Below
❑ Conservation -Commission Fling
(if applicable)
❑ Old Kings Highway $ Historical
Commission approval
(if applicable)
4of 4
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigadons
600 Washington Street
Boston, MA 02m
• www.mass:gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizadon/Individual): / i r e ..� /-4 S c+ n G
/2 ►3t r, d
Phone #: s-PT 3 3 5 - 73 a S—
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
ployees (full and/or part-time).•
2. I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
3. ❑
3a. ❑
required:]
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. iasuranCe,t
5. We are a corporation and its
I am a homeowner doing all work
officers have exercised their .
myself: [No workers' comp.- - - _ . __
- ---.right of exemption per MGL --
insurance required] t
c. 152, § 1(4), and we have no
I am a homeowner acting as a
employees. [No workers'
general contractor (refer to #4)
como. insurance required-1
Type of project (required):
6. ❑ New constriction
7. Q Remodeling
8. Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
•AI
ny applicant that checks box #1 must also all out the section below showing their workers' compm�odpolicy informaiion.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContracton that check this box must attached an additional sheet showmg the name of the sub-eouttscton and state whether or not those entities have
employees. 1f the have employees, they must provide their workers' co policy
mp. P cy number.
I ant an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaratlon 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 S1,500.00 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 inure coverage verification.
I do hereby jertl�rnder theme o penalties of perjury that the information provided above Is true and correct
L
Phone #: S-077 3 3 S - 73 a .—
Official use only. Do not write in this area, to be completed by city or town ofreial
City or Town:
Issuing Authority (circle one):
Permit/Lkense #
a- Y-i 3
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
Information and. Instructions • - 2 .
Inform_
Massachusetts General Laws chapter 152 r T*a all emPloYha to provide workers' compensation for their eMP10Y6-
is defined as "...every person in the service of another tt�er any contract of hire,
pursuant to this sterna., an twplget '
express or implied, oral of written."
" corporation at other legal entity, or any two or more
Aa �svpfgsir is defined >s as insiividusl, parttxrship. >ssocis<ia4 �n of a deceased empbya, or tits
of the fonping engaged fita Joiw enterprise, sad including the legal rep
resenwives receives or trustee of an individual, partnership, a:socr ens err otba leW entity. employing empWyem However the
owner of a dwelling lease having not tone than three �ents and who resides thae� cc the otxtrPsw of the
dwelling house of another who employs Persons to do •n construction a repair wort on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be as m>pbyer."
MGL chapter 152,123C(6) duo states that"every state or local licensing ageoey shall withhold the hsaaaa or
renew&! t(a Ucenu or perrak to operate a bnslnew or to eonatruet buddtap is the eoarmoawealth for aq
applk&at who here not produ"d seeept&ble erldeaes of eomPltsaee wide rho Insta&aee eorsrap regdr�"
Addttloaslly, MGL chsptes 152,12SC(7) states "Neitha the commonwealth nor nap of its political subdfvWM shall
eater into say contact for the paj=nwe of public wort until acceptable evidence of compliance with the insurance
rCTffi menu of this chapter have been presented to the cont<scting =dw ty."
AppQaab .
Please fill oar the workers' cmT1P0=dM of idarrt comPleteh'. try checking the teas a that apply to yaks situation and, i[
neeesauT, supply ems) name(o)q sddtess(es) end phone number(s) along with their certificate(s) of
(LLC) or Limited Lisbift Putoashipe (LLF) with an employes other than the
iaembeca. par Limited
_ i mmme. If an LLC oe LLP does have -
member at partners, Moot required m carry worioRa' coaspemstlon
employees, a policy is required. Be advised that this slfidavft my be submitted to the Department of fadus>zW
Acctdeab foe confirmation of izmaaace coverap. Abe be tars to sip and date the amdevit. 'Ibe affidavit should
be returned to the city or town that the spplicatioa fa the permit ere license Is being requested, not the Department of
Industrial Aeeidenb. Should you have any question. regarding the low at if you are required to obt da a wodoers'
compeasatloo polity. pl
eas can the DepartmxsY at the."" 1 r listed below. Self -insured companies should enter their self-iawaaan lieeau number on the liaR
City or Taws Of lelak
Please be saes that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the &!$davit for you to fill out in the event the office otlarestigadons has to coated you regarding the applicant.
Please be sure to till in the permit icense number which will be used n a reference amnber. In sdditiou.an appliaw
that mat submit multiple permit icense applications in any given year, need only submit and aPAdsvit h diestinS current
po1iy iniorroagaa (if necessary) and umda "lob Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stsmrped or marked by the city or town may be provided to the
applicant w proof that a valid &M&vit is an fad for fldt m perarits err licenses. A new affidavit must be filled out each
year- Where a home owner or citizm it obtaining a license or permit out related to any btrioess or comarreisl venture
(Le. a dog lieeme or permit to bum lend ere.) said person is NOT required to complete this affidavit
The Office otlnvestigations would like to dw* you in advance for your cooperation and should you have any quesd ere,
plena do not hesitate to girt ns a call.
the Deparimew's address, telephone and fan number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofltee of Imratiptlons
600 Washington Street
Boston, MA 021 It
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 11-224)6 www.mass.gov/dia
yo TOWN OF YARMOUTH
r.: s BUILDING DEPARTMENT
• CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT:
job Location: _;L 7 7 Q r
Number Street Village
Owner of Property: Son tire fJ ic, , o v u -r n f L_ 4 C
Construction Supervisor.
Address: r417
Licensed Designee:
(If other than Supervisor)
Name
2.15 Responsibility of each license holder.
v 5/ 9-
115
Na.
SzF yS�-�vs J`
License No.
Phone No.
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the -state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfullyviolate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities tinder the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes No ❑
If you have checked yu, please indicat the type coverage by checking the appropriate box
policy A liability insurance . Other type of Indemnity ❑ Bond
OWNER'S INSURANCE AIVER: i am aware that the licensee does not have the insurance coverage required by
Ch 152 of th Ma . General Laws, and that my signature on this permit application waives this requirement.
�✓ Z., .-,c Check one:
Signature of owner or Ownees Agent Owner Agent I�
Signature: Building Official Approval:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext.1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section It 1.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 271 Svv4-1 S4-3r-e @r,. c.�u�yrl0v��j
Work Address
Is to be disposed of at the following location: U4111
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Segkon 150A.
of Application
Permit No.
Date
t7�rYnnr,
Office of Consumer Affairs & Business Reeulatio■
•-F-�;k-:-�41JOME IMPROVEMENT CONTRACTOR
��14-4�eglstratlon: 126577 Type:
�ttxplration:-6/2=014 Individual
ROBERT P. FASANO `.
ROBERT FASANO
12 BIRD RD ��
MANSFIELD, MA 02048 Underseerchry
'%1a%.achu.ct1. - Dcpartmcnt of Public !%:dcq
[/j Rnard om_ f RuildiRv-ulation+ andta Nndard.
�J
License. CS 71576
ROBERT P FASANO
12 BIRD RD
MANSFIELD. MA 02048 ---< •_ _:
Expiation: 7/1&2013
( .uuui..i.aKr Tr--: 18333
Surf Sand
on Nantucket, Sound
... • .I if . .• .
February 4, 2013
To Whom It May Concern:
Please be advised that I hired Bob Fasano to perform the work at the Surf & Sand Resort Motel at
277 South Shore Drive, S. Yarmouth, MA.
Th nk you
V-1k
Sandra DiGlovanni
Manager
277 South Shore Drive
So. Yannouth, MA 02664
508-398-3700
TOWN OF YARMOUTH
Building Department
Town Hall
Yarmouth, MA 02664
(508) 398.2231 ext.1261
BUILDING PERMIT
TRANSMITTAL
Temp Permit No.:
T-13-276
Applicant Name:
Robert Fasano
Applicant Phone:
5084988055
Building Location:
0277 SOUTH SHORE DR
Owner's Name:
DIGIOVANNI, SILVIO V
Owner's Addres
P.O. Box 1282
South Yarmouth MA 02664
Owner's Telephone: (508) 398-9556
(OFFICE USE ONLY
Recorded By.
IC
Permit Fee:
$0.00
Deposit Rec:
$25.00
Payment Type:
Check ChkNo.: 1016
Net Owed:
($25.00)
Application Date: 2/4/2013
Issue Date:
Expiration Date
Comments: Map/Lot: 026.127
remodel existing kitchen & bathroom in units 101,
102, 103, 203, 118, 218
REVIEWED BY:
1. WATER DEPARTMENT:
DATE:
N/A:
2. ENGINEERING DEPARTMENT:
DATE:
N/A:
3. CONSERVATION:
DATE:
N/A:
4. HEALTH DEPARTMENT:
DATE:
N/A:
5. BUILDING DEPARTMENT:
DATE:
N/A:
6. FIRE DEPARTMENT:
DATE:
N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY:
SIGNATURE OF APPLICANT:
DATE:
Date Printed: 2/6/2013
1c w►Ode, l cJ n , S .7s
03, I�,
I
1
/`ro•�) Doe r—
soncjrct olutovufill ni, /. C C:
TOWN OF YARMOUTH
% SO v-t S r r` Dr. REVIEWED ERRORS OR I LDING AND ZONING CODE COMPLI-
ANCE.
OMh SS ON DO NOT RELIEVE THE
/� APPLICANT FROM THE RESPONSIBILITY OF 'AS BUILT'
l.1 ct / Wl0 U y' Q L L COMPLIANCE.
DATE: Z ,6
BUILDING OFFICIAL
FILE COPY
-S -Tr /o,- ,
f
1
It
a
y 0
Aro•�
Su n Jr el 011 to v a n n I
;277 .S00-�; S;ure Dr. TOWN OF YARMCUTH
A ANCE.REVIEWED FOR BUILDING AND ZONING CODE COMPLI-
�.f DO NOT RLIEVE TH
cY r N d v41fl yJ�% rJ G y APPLICANTOFROM T HOE MMISSIONS RESPONSIBILITY OFE AS BUI Tt
COMPLIANCE.
DATE;
BUILDING OFFICIAL
APPLICANTS COPY
BUILDING PERMIT APPLICATION
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF,
OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Tulvrl of liununtth Building bcp:u-tlnrnt
1 146 Rnutt- 28 • litnncmth, %L: 0266.14 NP2
Tel: 508-398-2231 exL 1261 Fax 508-398-0836
Office Us
e Only,,� FEn
oard Infomiabon Assessors Department Information:
Permit No.RaiJM,�pkl or�Permit Fee $�] �Date dv--te New
Deposit ReC d. $ Dat Plan No. 1.4 Property Dimensions:
Net Due $ Other Lot Area (sf) Frontage (ft) Lot Coverage
ISlgnature: II Certificate of Occupancy I
t3wldlrp official Date Is is not required
Section 1 - Site Information
1.1 Property Address: 1.2 Zoning Info7wwn:
_,,7g?7 5001h 5"Ic zxe
Zoning District Proposed Use
1.3 Bulldlna Setbacks Ittl
Front Yard
Required Provided
Side Yards Rear Yard
Re uired Provided qu r de
1 A Water Supply (lLQ-- c. 40. S 541
Public Private
1.5 Flood Zone Information:
Zone; l3FE:
EB 12 2013
Section 2- Property Ownershi Authorized Agent
BUILDINGDEPT
Name (print)
Signature
2.2 Authorized Agent:
Mailing Address:
9q6 E. Telephone
N nle ( runt) Mailing Address:
�ignature Telephone Fax
Section 3 - Construction Services
31Llcensed Construction Supervisor. NotApol,cable
ll ,_ r^_
license Number
3
Expiration Date
l
t of 4 OVER
� •l
2 Registered Home Improvement Contractor. EL
Company Name ���� ovW �//1Q1c - Not Applicable
-L-/' 11-1�-='I�� �6=F IY `�' '( Realstration Number
OQLI '/ - V 19 - -I J I
I Expiration Date I
Wit ture Telephone
Section 4 - Workers' Compensation Insurance Affidavit (M.G.L c. 152 S 25C (6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the de ial of the issuance of the building permit.
Signed Affidavit Attached Yes .......... No ..........
Section 5 - Professional Design and Construction Services - for Buildings and Structures Subject
to Constriction Control Pursuant to 780 CMR 116 (containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect:
Not Apptkable ❑
KJ
Name (ftolistrablill
Registration Number
Address
Signature Telephone
Expiration Data
Section 5.2 Registered Professional En ineer s
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Noma
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
2ot4
r- r
� ....1tw-- Q _ nnewrinlinn n1 OrnnneDA Wnrlr !r_hwfJ[ 9rt JmeCanlei
New Construction ❑
f (for Mull 1pl amity only) No. of Bedrooms
(lot multiple lamity only) No. of Bathrooms
Existing Bldg. ❑
1 Repalr(s) 9
1 Alterations ❑
I Addtdon ❑
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work:
1
S
1 v
Complete this section If existing budding undargoitV renovations, additions and/or change In use.
Exleerq Use Group: I Pmpoad use Grow:
Hazard Index 7e0 CMR 34
18 Buiklkta Helaht and Area
Ntxnbv ar Bows WON"
k+Mrde bmwr wt kw"
Floor Area per floor Ise
Total Area AN Floors
Total H"d (ft)
- STRUCTURAL PEER REVIEW (780CMR 11
Structural EnoiowkV Strucbxel Pow Rwlow ReWred
i 10a OWNER AUTHORIZATION - TO BE CO
Proposed Haxwd Wax Teo CMR 34
Yee ..........
BUILDING PERMIT
No..........
--�sOwner-of the subject property. —
hereby authorize {' Ski 2 10C ' to act on
my behhhalff,,in all matters relative to work authorized by this building permit application.
A $1 l?7
Signabue of Owner Tloate
3 of 4 OVER
� IJ
ECTION IObOWNER/ AUTHORIZED AGENT DECLARATIonr
I. l r 7` I ,4 5 t to cz 3-bZll�� , as Owner/Authorized Agent
hereby declare that the statements and Information on the forgoing application are true and acurate, to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
I Check Below I
❑ CmWWvMIorWorWWalon Fillrg
(H applicable)
❑ Old Mqp HVYway A HistorleW
Commission approval
(if appkabls)
4 of 4
Nov 131211:24& p.1
::f09/2012. 14:11 75199?2655 EM R,014 INC ' PAGE 03
snow;u
rile almsq t:otrvrun
vtl MAINSI'K!'.Ia
w,At:IIIAKMNW-141 1�►
�cUll�
-rd.11lltito}d?tn J
rxx «elt sw•;'.n�� � - � t{• o71a ' S3 v I'o
I .
_ _ _.. --•�IZIFN
WxContractStihmined l'n:Attn!Candra DICInvaStnl & Mr.DIClov6 lcasllcnfalsultli Lsr s c t,gh!`LLL"- M9/20111
Su ell Sand - '-_....._. _S:net •PO Boi �7N dlip nMAU26b1hor�gl?n a5ccthYarmouth
tie,cspclsnn
IC k Job l Job Phone
Doer Snow _ 1107256
We htreny su:lmil sneclllcatkws and st'rlates for:
install thirty -sill 136) Thernta Tru 5210 6.panei Smooth Star. F.ntry doors
• Spill steel Jambi, salt-rla<ind, brushed nickel hinges, brushtd nickel entry seta aad brushed nickel deadbolts
Wars and jamb, to ht ractoty palrtted sthl:r or other Inside and out ;
• PVC Irim In h< u!rd to (rim exterior. primed pine trim oa Interior
Caulk as necesian
Inus:t thirtycls (361 Thermo Tru St19 Full-Lite Smooth StarFntry doors
Impact rexWor.1 Risst
• Sp!I! steel Ja mht. srlf•tbsiAX, brt:shed nickel h)n,5q, brushed nickel entry se.s and brushed nickel deadbolts
bnnrs and jacnhs to he rarinry palated white or other Insure and Oct
PVCt Irim e•s he urged In trim exterior, primed pine trim on Interior
Caulk ac neressan
1 Irsttll one Therms Tru SI Di Slat) Smooth Star Entry door
PVC:',larob, erlt•rl.ninG, brushtd nt:ke! hinQa, bruthad nickel entry sett and brushed nickel deadbe)p
I)nnrs anti 'Amht in he ractnry painted white or other Inside and cut
PVC trim to he Cued in trim exttrlur, priaird pine trim oa Interlor
Caulk At necettan
Clear aad rent[We Orhr)s caused by ut
IC .car labor we reality. JLNbut Installatietl detects• Manufacitirer's warranty en materials.
ria} etr t' ii, c errernenl It), hss her, cons=rixicd oy a piny Cher. a a: a place othtr Ihar, the addrest c?tna $itter t:hiei
nay bt hit Hain n[fi: t or t ra'u h ihereloft+y a written notice dtrected to the sal Icy at his Main or branch Office by ordinary mdil posted,
betel: �m tent n: Fk delivery. not liter than midniphtof the third business day foliawia)t •he signing ci•this tpreeTent"
We Prttpctse Iter�hy In rumi;h ruterial and tabor- cornplete in accordance with shove Specificatiors. for the
c 1m 4t: One h undyed fifteen thousnrrd live hundred & 00/100a"*"""'""'"««" Dallas 5115 500.00
I r - u uc U n.c r..... .,,,-
r3"` UOW� Y4 If3r" UPON It2 CONIPLUInN, FINAL PAYMENT DUE IN FULL ON DA
Al! mUoiei,s jllxihutttll b• rt r' Ipat+Led. At 41.1ri ie R C• ,metee�o n wtvlr+:Nice Mnre•
•,u A101a 4' x,a Aito tin+�4t't!. 4er4i,, et turednnJ enn¢ 1094 w hit'i, I60110"1 of relsi<..of
s:ftrdt.x•twq �c.•ahan+li•nWdt1•I>;I{Putton 'JwvctneA.lGalanliuwtivht{C&IIcrs!swIII Ili:
i rtCCJICd er.l. nAin miytr i•rdt•t. rid will 99ee19 16 Kin outye •r)cr %rid Vo.r nu tstuTNt. All
npem+enlr rtnli'1{tr+1 t rM vr1Atss n:cWenu or Jc4yx Fien•nJ twr eln:rel i:,+E:T Pi carry rue.
1pniPJO Anil nfYe nr:[u+n hnunln;r I lum:oveer w.l� ho re,riltra:btC rel d�lYn•1q cleor+ca) w,dni
I ant+ Axwte Co,tir icinrnJ, -Tip t,r,k li.r ntNC. Corvhcnx nee re.+pirai is IM 411d Wiel rrm.trhi.
t7t.r LLiultees ine +il.h' .v,e•tt 1•r :tiirslnrn'S CTny:tcaritue inSuruKe.'l lie humpn.:ter hn the n phi
IP srhd talc it' Iitirj • II,, W1 4 mi•AICor.)t'ant Ypp�adOt:<tlrt•ery of Clin1k:1ttf Alreln. l: ornaalY
Acteptantr l nt Prrtivsal - 1"Itc Ilhart nrlc" spatr1calien and crrditiwu ore a 1alicttry
n Ant Are htrGhw aralo I. V nn ire nn111ortred (or do Ole work 63 Sped:itd. 1'1tviprn; n III he
Made a: u,.11ird ul+ac
Hale:, Acrtpt:eue _.
Kota: This proposal may be wiCidriwrl
by us ii not auept:d whhin _)_Ldays.
� 4
VV P
TOWN OF YARMOUTH
�+� C BUILDING DEPARTMENT
o y 1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed/work/demolition to be
conducted at�Z 00fh 5"k 'V1 f:5,tl2r $ �`j7✓�� ���� �-Irq-p�cff�
Work Address
C(o CAVOssA 1>r',>P0SA4,
Is to be disposed of at the following location: NGIJ b6PFOAD LvA5T6� -' IV ,Du/iCOI (YIi-
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Application
Permit No.
�L-1- )3
Date
•4 O
PLEASE PRI1VT.
job Location:_
TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
_ 5o a ( 51}N-0 _ ,
Number
Owner of Property. -
Construction Supervisor:
3FAM
Street
Ilage
A'alliv j 'License rvo. Phone No.
Address: � I: A l��l�—I 4460 MA A "C.�i�_l
Licensed Designee:
(If other than Supervisor)
Name
License No.
2.15 Responsibility of each license holder:
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licenseewho shall willfully violate subsections 2.15.1, 2.15.2 or2.15.3 oranyother section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities tinder the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COWMAGE:
have a curren ,ability insurance policy or i substantial equivalent which meets the requirements of MGL Ch.152
.___._...._._Yes_.. _.___.._._._.___—No_�--
If you have checked yu, please indi to the type coverage by checking the appropriate box.
A liability insurance policy Other type of Indemnity ❑ Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Ow6 r or Owner's Agent Owner ❑ Agent
ME
Signature: �i� A;� Building Official Approval:
jam(�/
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisur
License: CS-069399
DOUGLAS E SNOW jL
971 hum at i ;� s
WALTILAAJ
Expiration
Conimss,oner OW0312014
Jhs 4'on..n.w.�wri/I.i y�6f�atwaEax/L
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
fx- expiration date. If found return to: before the es
-`�;7 f301IE IMPROVEMENT CONTRACTOR P
e9istrall0n: 103258 Type; Office of Consumer Affairs and Business Regulation
iratlon" - YU2014 . Private Corporation 10 Park Plaza - Suite 5170
_ Boston, NIA 02116
E.M. SNOW INC.
DOLGLAS SNOW
971 Main St.
Waltham, MA 02451 —��—
Uudersecrctary Not valid without signature
The Commonwealth of Massachusetts
i _,.,.pris7Giy
Department of Industrial Accidents
Office of Investigations
600 iVashington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual): E.M. SNOW, INC.
Address:971 MAIN STREET
vvr%. t nruvt, rvim uc-ta t
Phone #: 10 i-ozy�-cvaa
Are you an employer? Check the appropriate box:
I.0 I am a employer with 10 4. ❑ I am a general contractor and I
employees (full and/or part-time)."
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.)
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.) t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance?
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
IL E] Plumbing repairs or additions
12.0of repairs
13.Ej Other EWWVW DDo
WCAC1; m � i
*Any applicant that checks box it l 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.
iContractors 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: STAR INSURANCE
Policy # or Self -ins. Lie. # WC0632074
Expiration Date 05/06/13
Job Site Address: -'VW e .W-0 02 . tbod 5W 57 7 2j_ City/State/Zip: l /VA
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). L(Q 1
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 cent fy under the gains and penalties of perjury that rite information provided above is true and correct.
.781-893-4546
Official use only. Do not write in this area, to be completed by city or town ofciaL
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone #:
-" CERTIFICATE OF :LIABILITY INSURANCE 09roui012
T1H3CERnFr.ATE IS =ZO AS A RATTER OF I).FORIAATION ONLY AND CONFERS NO F.:OHTS UPON Ti C CERTIFICATE HCL M INS
CERTII'1„^ALE DOES NOT AfFLFWATi'VCLY OR NEGATIVELY ArALNO.EXTr.AD OFIAI-IERTKE COVERAGE AFFORDED BY THE POLIZX3
OLLDiV.THSCLRT.FiCATEGFVOLUa NCCDOESNCTCONSTITUTEACONTFACTDCTt1'iLNTHtISSWNOINSURERJS�AUTi60RIZED
REPRESENIATIVE ON PRODU"R. AND THE CERTIFICATE MOLDER.
IMPGA7A&'T: If IN carvcuo holdar Lc an ADDITIONAL 14SURED, Ms polwcyyss) minibe ondanad. It SUBROGATION IS WANED, sub,*d to
tha tons ana towlwia ut NN tl.)WLy. wui11 v.Airoes RIaT IKTirs as eg11JT'Aso tiamr. A ilatrm ord a. Itch rAf14 Nta five* riot cvIrar I$4 NY to ths
csrnbcats Aoidaf in Lou rA auch end.anatnant(al. '
IitD4'LCtA
,,,,, Gran Voslw h
Agency, Inc.
Mason t ►tason Insuranco A
h -�-- --- �.__ � 4ii.7210
��+,' It,T,,, li1.Aa7.SS31
i5i South Ave.
L'yui*t
''
khltran, FbL 02152
_�...
II.OGIt[a
cwra'r�c.Elr�t,
Gen Vosburgh
ws wu t)An inD..
h/1 G47PV..i Mr:a-
.,,wrl:.,, _ First Mercury Tniwanco Co. -
RI4ATD
EM Snow, Inc
wwacnal D002H
. ....,.... -
971 Rain St
..Star-In.uraaca _ ,
sL"IAC�
Mal tham, KA 0I411-7406
WILMA C I
THGIBTDCtATFYIIIATTICF'QwC"OfW44,,%1"u;TL7baCWI )OT-rxfN=.,CZTOTkIZItGU;=MALOAWvLrORTIC,PCUCYP:.7=
Me,,ATCO NKTTW TItSTAhCaIO.,ANY R:ZJKtK rl.TEHAI CA GOt♦4MM Or ANY COW,PAZT OR OTtt R DRZULCHT W r'N .IT.IMT TO WnOi Psi
CM F" E ►OA1 BL E4Ji.DOH LW7 IV1rAN, Ti,E U9WfW'w".'c AF I-Ovi; n0 BY TFE I9Ll:IES CE.&GnBCD FLfikT.t Fi iil,FrJcCi i17 AL1THE 7Efih,6.
:.A4LU91Otii NaO COMYTICtt� O/ 3L01 ai ICr3 La.^. S 6?"N 14 UAY ra'.•, M % RCDU= by rA:1 GL "0
•_ mcvru.wnar_,- X>r:"a.......�...�..�. M_KYtiI'i COIr.YT3i.'^"�'.�"' .�..�__....__ _- .._...
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PLtry A4vKl.«."R 1par Al'h K.t ►CY1
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aA.tCK'Oia NAAR" 1
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OFFICtR IS INCLIFO
aI. *tar+*e•r1'eaw.�Jrer • 300 0
a'/hYN 1
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� .V^.i.r I.V 4V •1.
FAX; 73t.143.2655 yOULDAKYOFINE ABOVE USCAIBEDPOUCIrtfBECARMItDF.EFORE
TIIC 93MATIaN DATE TICUCIf. ata=C Tf" CC L46hgRCO IN
&=OR: U'CE "Iki the POLIO► PiwnsiONS.
E.M. Snaw, Inc.
Attention; Lauren Gaffey
971 Rain Street
Waltham. RA 02451
A* W P.=a ILULU&JITAPIZ
ACOIW CORMRATION.All
ACOR.7 231TL 4415) TI►s ACORD halve arad Wpa am t"iwveod ttwl4a of ACORD
BUILDING PERMIT APPLICATION
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF,
OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
'rown oFYannouth Building Deparhnent
1146 Route 2R - tiitrn,outh. CIA 02(iti4-1.11)`L
Tel: 508-398-2231 eat.1261 Fax 508-398-0836
Office Use Ontinly
Permit No. Dates
Planning Board Information
pe
Assessors Department Information:
Map Lot
Permit Fee $.-;2 70
Endorsement Date
/
Deposit N
q7scor ing Date
New
Rec'd. $ p� Date
Pin No
1.4 Property Dimensions:
Net Due
Other
Lot Area (sQ Frontage (it) Lot Coverage
This Spc9on for Office Use Only
-duilding
P rmit umber.
Date Issued:
Signature: -G LAE
CerfiftateAfOxupancy
Building O D
is is not required
Section 1 - Site Information
1.1 Property Addreast
1.2 Zoning Information:
Zoning District
Proposed Use
1.3 Bullding Setbacks (ft)
Front Yard Side Yards Rear Yard
Required I Provided Required I Provided Required I Prnvidad
1.4 Water Supply (M O.L. c. 40. S 54) 1.5 Flood Zone Information: Cornments:
Public x Private Zone: BFE
Section 2 - Property Ownershi Authorized Agent
Z r of R rds
N me (print) Mailing Address:
1- -79 9!4
Signature Telephone Telephone
2.2 Authorized Aoent:
V P)
me ( )
""
5 n ture
- t/RW-
Sv 7e - ys
Telephone
11G4 uvX"
Mailing Address:
_ vs- Wd
Fax
OL t WL4.'16
95l R E C
action 3 - Construction Services
3.1 L eetdsep
ruon upe�r)vison
C091,
ay
Not ApplitOt
v
030 �t / 1 W 1,� /
J C /� l.�
p+ 02 ,/
V 0 J
License Number
-7! ,/ S f
ddressrs/ /�'
/f`7 l /
����7� D `%s•sl9 4•-
Expiration Date
0
1 of 4
P _25-2012— -
7� OVER
DUI DING DEPARTMENT
BY. —
3.2 Registered Home Improvement Contractor.
Com y N 7
Not Applicable ❑
Registry i � 1 r
Y`
A14dyes t <<� f'- W f W
l d 0 G L' 9� %
Expirat Da
ig ature Telephone
action 4 - Workers' Compensation Insurance Affidavit (M.G.L c. 152 S 25C (6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the denia6of the issuance of the building permit.
Signed Affidavit Attached Yes ........ No ..........
Section 5 - Professional Design and Construction Services - for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116 (containing more than 35,000 c.f. of enclosed space) .._j
Section 5.1 Registered Architect:
Not Applicable EJ
mama Ineglstranth
Registration Number
Address
Signature Telephone
Expiration Date
Section 5.2 Registered Professional Engineer(s)
Name
Area of Responsibility
Address
Signature Telephone 1
Registration Number
Expiration Date
Name
Area of Responsibility
Address -
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Section 5.3 General Contractor
OA 6
Not Applicable ❑
Com ny N me
P son Re ponsible for C ns on
TM 5A--TKD-�q1"f-
SiVatufa Telephone
2of4
'O (iWn^
Section 6 - Descrintion of Pronosad Work (check all anelicahlel
New Construction
❑
1 (for multiple family only) No. of Bedrooms
(for multiple family only) No. of Bathrooms
Existing Bldg. ❑
Repair(s) ❑
Alterations ❑
I Addition ❑
Accessory Bldg.
❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work: L ��
W L �yi el i T D u,"i f O / cu c, D. ovo ej y (�
G4(
yle t/G
Secton 7 - Use Group and Construction Type
Building Use Group (Check as applicapable)
Construction Type
A ASSEMBLY
❑
A-t ❑
AJ ❑
A-2 ❑
A•5 ❑
A-3 ❑
1A ❑
186 ❑
B BUSINESS
d
2A ❑
28 ❑
2C ❑
E EDUCATIONAL
❑
F FACTORY
❑ F-1 ❑ F-2 ❑
H HIGH HAZARD
❑
3A Cl
38 ❑
I INSTITUTIONAL
❑ 1-1 ❑ 1.2 ❑
1-3 ❑
M MERCHANTILE
❑
4 ❑
R RESIDENTIAL
❑
R-1
R-2 ❑
R-3 ❑
5A ❑
58
S STORAGE
❑ S-1 ❑ S•2 ❑
U UTILITY
❑
SPECIFY:
SPECIFY:
SPECIFY:
M MIXED USE
❑
S SPECIAL USE
❑
Complete this section if existing
building undergoing
renovations, additions and/or change In use.
Existing Use Group:
Existing Hazard Index 780 CMR 34
Proposed Use Group: f
Proposed Hazard Index 780 CMR 34
Section 8 Buildina Helaht and Area
Building Area Existing (if applicable) Proposed
Number of floors or stories
Include basement levels
Floor Area per Floor (sf) Ivu cj1
Total Area All Floors (sf)
Total Height (ft)
Section 9 - STRUCTURAL PEER REVIEW (780CMR 11011)
Independent Structural Engineering Structural Peer Review Required Yes ......... No ..........
SECTION 10a OWNER AUTHORIZATION - TO BE COMPLETED WHEN
M
/� �i/ ,, , as Owner of the subject property,
/ �Vi ,�(// f�
hereby authorize fn to act on
my bbeh�alf,. in all matters relative to work authorized by this building permit application.
Signature of Owner Date
3of4
OVER
SECTION 10b OWNER/ AUTHORIZED AGENT DECLARATION -
as Owner/Authorized Agent r
hereby declare that the statements and Information on the forgoing application are true and acurate, to
the best of my knowledge and belief.
Signed under the pains ,and penalties of perjury.
Q
o5 �? �V l ref
i t NarAe
I nalbre of owner/Agent Date
5(ection 11 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be
completed by permit applicant
1. Building
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
5. Fire Protection
S.Total a(1+2+3+4+5)
7. Total Square FL (for rew MOM M a +)
Check Below
❑ Conservation -Commission Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(it applicable)
4of4
The Commonwealth ofMassachusem
Department oflndus&idAcddetrts
Office oflmestigations
600 Washington Street
Boston, MA 02111
www-Hu=gov1dia
Workers' Compensation Insnrance Affidavit: Builders/ContractorsMectricians/Plumbers
1. d (fix
F
1 MA 0-26K Phone
A,r_e�°u as employer? Check the appropriate bom
i. I am a employer with 2, 4. I an a general contractor and I
azoployoes (f M and/or part-time).* have hued the
2.0 I am a sole proprietor or part= -
ship and have no employees
working for mo. in any capacity.
[No works&' 00r0p, insurance
required
3. 0 •I am a hom=wner doing all work
myself [No worlmrs' comp.
insurance roq4irod] t
listed on the attached sheet.
These sub -contractors have
employers and have workers'
comp. insmanoe.t
5. 0 We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § l (4), and we have no
=Ploy=. [No workers'
comp. insurance remlirLal
Type of project (required): .
6. ❑ New construction
7. ❑ Remodeling
a. b�e nolitioa
9. 0 Building addition
10.0 Electrical repass or additions
11.0 Phmtbing rcpaus or additions
12.Q Roof repairs.
13.0 Other
•Any APPu�t that checks box #1 must oho M out the esdam below d owmg their workers' ca=p=sadoa
t Homeowner who submthis and" it Po�Y iafarmatioa
g mey am de>�g � wort end thus hire outride eontrectms mart tabmit a new aMdavR wdjr+� mrh
tCoahacma dW chxk da box mast attached as Additional &beet showing a= name of the cub-coatractnrs and Oft wlu Sher or not those sadder have
eaPlayea. If tbe snb-mnwwtna have ®ployoq they must provide tb= workers' =M;L pot Cy manbe.
ram an employer that is providing workers' coarpensaaon haLw=nce for my employees. Below is the polity and job site
information. �-
Insurtaaco Company
Policy # or Self -ins. Lis #: 1 3 / %L)(O 212
Expiration Date: ,g
Job Site Address: City/Statmzip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Fail= to scare coverage as required Under Section 25A of MGL c. 152 can lead to the imposition of crhmmal penalties of a
fine tap to $1,500.00 ®d%or one-year i n;=onment, as won as civil penalties inthe form of a STOP WORK ORDER and a fine
of tip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lm'estigationsA the DIA for insurance coverage verification.
14 hereby
ofPQJw3' that the information provided above is true and correct
official as' only. Do not write in this area to be coarplrted by city or town official
City or Town:
Permit/License #
Issuing Authority, (circle one):
L Board of Health 2. Building Department 3. Cttyffown Clerk 4. Electrical Iaspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
PLEASE PRIM:•
job Location: _
TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
�12414,
Number ' Street
Owner of Property: - 51 / 1"I U �1 �IO i✓p4M1
Construction Supervisor.
Address:
Licensed Designee:
(If other than Supervisor) Name
2.15 Responsibility of each license holder:
14f
License No.
License No.
f--761)- fRf
Phone No.
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is, not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfullyviolate subsections 2.15.1, 2.15.2 or 2.15.3 or anyother section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities tinder the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
I have a curve liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes No ❑
If you have checked yo, please indicate the type coverage by checking the appropriate box.
A liability insurance policy . ❑ Other type of Indemnity ❑ Bond ❑
ER'S INSUR CEWAIVER: I am aware that the licensee does not have the Insurance coverage required by
ter 152,ofY as General laws, and that my signature on this permit application waives this requirement.
UChec ne:
e of owner or Owner's Agent Owner W Agent (]
Building Official Approval:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, NIA 02664
508-398-2231 ext.1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section It 1.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at l l-A lice
Work Address
Is to be disposed of at the following location: OX4 w ae-
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
DOki-Lc% : 2
of Application ate
Permit No.
Clientil
' � ZNORTIIBAYAS
ACORD. CERTIFICATE OF LIABILITY INSURANCE ED"A�;:��THIS CERTiF7CATE IISA WTTER OF WFflRWTONLYAND
CERTIFICATE DOES NOT AFFIRt1ATNELY OR NEGATIVELY CONF� RICTiS UPON THE CERi1RCJ1TE HOLDER THIS
BELOW. THIS CERTIFICATE OF WS(1RANCE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
STITUTE A CONTRACT� THE ISSUING, WSURER(g� AUiHORD2 D
WPORTANi: N the cert(flpL holder fs an ADD11pNAL MSURED, the 1110ry(N1) must be sndorselL N SUBROGATION tS WANED, sulHject to
the terms and conditions of the poll cabin cepolicks may require an endorsement A statemerd on rttOcate holder in of such endorsemelHt(ZJ this (cats doss not Cortfer rtOhts to the
Dowling 3 O'Neil
1wzg.w.
Insurance Agency
508
E+IArL
973 anrwu
N gh Rd., PO Banc 1990
Hyannis, MA 02601
WSURED
MM R M A. Nail
Joseph Butler
HMSIMIBt a: Train
DBA Norihbay Associates
bdSL Rel C:
P.O. Box 1197
e� D:
South Yarmoutin, MA MU
f+slnel E:
INDICATED. NOTWRHSTAAIDPIO ANY `...,.`.r".c wIcu tILLUM HAVEBEENISSuM TOTIQ: NAA1 DABOVE FORTFE POl1CYPERIOD
CERnFICATE MAY BE ISSUED OR MAY •TERM OR COI OF ANY THE
OTHER DOCUMENT yyn}t (-W= TO WH3CH THIS
AC THE MMINSgwCE BY TFE POLICES DESCREED t6HEfi iS SUBK= TO ALL THE TEWs.
wr E%C<A1SIOr� AND CONDHiIONS OF SUCH PCilCa64S L,IfiS SHIOWN WY HAVE BEEN REDUCED BY PAD CLANS.
A I MMIAluAesnY YPF7496Y
B •�rrscar�rciaOHH
� -.-, ellLAFFEu"33�22
DESCRWMM OF OPERATKMS/IOCAMMI WH3eCLW(AdcMACORD w% AdAiltaw.l R�Ys g k d.1 .f." "W"
Insurance Coverage Is limited to the terms, condttions, exdusions, other t)mitabons and endorsements.
Nothing contained in the certificate of insurance Shan be deemed to hamafteI waived. or exterxW the
coverage provided by the potky provisions.
Town of Barnstable SHOULD Arty OFTHE ADM DEsCREM POUCEs BE
CANCEMED 200 Main Street - THE t•7I WATION DATE THEREOF. NOTICE %VLL BD RBEFORE
01
Hyannis, MA 02601 ACCormANCE wrrH THE Pal p#WWM ores.
AUTMOROnRa FxrAnvE
ACORD 25 (2010/O5) 1 of 1 Tha ACORD name and 019SU 1110 ACORD CORPORATION AB riph 3 "served.
f)S91071IM91070 IDD0 cos M9Wwsd marks of ACORD
LS1
i
HOME oR
Tjpc
3 DIM
L�
RRAYASqRC'—- •,
JOWH _
91 SOUiH
SOUiI1Y
M 'ftclnmtt�- Ucpanmcut of Public $arch
BoaN or Buildinz Rctulatinns and Standards '.
lion supervisor License
tk*nsc CS 714M
!K)SEPI•I A BUTLER —
PO BOX 306
E HARWICK CIA 02M
j
y
ExpraUm 52gaMa
Tr,— 19908
HOME oR
Tjpc
3 DIM
L�
RRAYASqRC'—- •,
JOWH _
91 SOUiH
SOUiI1Y
M 'ftclnmtt�- Ucpanmcut of Public $arch
BoaN or Buildinz Rctulatinns and Standards '.
lion supervisor License
tk*nsc CS 714M
!K)SEPI•I A BUTLER —
PO BOX 306
E HARWICK CIA 02M
j
y
ExpraUm 52gaMa
Tr,— 19908
FILEICOPY
TOWN (IF: YARMOUTH
REVIEWED FOR SUV 'dG ",ND ZONING CODE MAI-
ANCE. ERRORS OR C :' MISSIONS DO NOT RELIEVETHE
APPLICANT FROM Th RESPONSIBILITY OPAS I r
COMPLIA,N,CEE
DATE __1/�
BUILDING OFFICIAL —leg -
D
O's
60 -
g
Ct qc( of !
Pi e p rc e i �► r 16 uhm -
vh;r aPl
Sip-rp5,o.4.0
2 -n S..� ou OR! ►C
,ya
• TOWN OF YARMOUTH
t Building Department
+� Town Hall
Yarmouth, MA 02664
(508) 398-2231 ext.1261
BUILDING PERMIT
TRANSMITTAL
Temp Permit No.: T-12-375
(OFFICE USE ONLY
Recorded By.
to
Permit Fee:
$0.00
Deposit Roo:
$25.00
Payment Type:
Check ChkNo.: 2702
Net Owed:
($25.00)
Application Date:
4/25/2012
Issue Date:
Expiration Date
Applicant Name: Joseph Butler
Applicant Phone: 5087604949 $b$- 2-Y&r 3o2,T.-c-;
Building Location: 0277 SOUTH SHORE DR
Owner's Name: DIGIOVANNI, SILVIO V
Owner's Addres 49 Glenn Road
Belmont MA
(will
Owner's Telephone: (SW 799-9199
REVIEWED BY:
1. WATER DEPARTMENT:
2. ENGINEERING DEPARTMENT:
3. CONSERVATION:
4. HEALTH DEPARTMENT:
5. BUILDING DEPARTMENT:
6. FIRE DEPARTMENT:
COMMENTS:
RECEIPT OF COPY:
PLEASE NOTE
SIGNATURE OF APPLICANT:
Comments:
026.127
Interior renovations to rooms 110, 201 and 202 -
new kitchens, baths and tile floors
DATE:
DATE:
DATE:
DATE:
DATE:
DATE:
I•"
N/A:
N/A:
N/A:
WA:
N/A:
DATE:
Date Printed: 4/30/2012
TOWN OF YARMOUTH BUILDING DEPARTMENT
+ PLAN REVIEW & BUILDING PERMIT APPLICATION REVIEW NOTES
ADDRESS: a :2 Permit Fee Calculations
Map / Lot:
Date of Initial Review:
Other Review Dates:
Inspector
Review Date:
Approval Date:
NOTES
Correction w
List �1t�
No.
Description
Code Section
Utt
Ave
s;Llk z h 6�--
Zoning Denial (if applicable):
Section 104.3.2, para. Change, Extension or Alteration (preexisting, nonconforming)
The proposed
Other
Building Code Denial (if applicable)
requires a Special Permit from the Zoning Board of Appeals.
h:pinrv&bldgpennit
Rev. 3R.1f09
�,►�pr•Yglq ro N OF 1 ARMOU H �(Z-[Z-fib
It' p BUILDING UEP.�R'rJ1eV r Permit Number
1146 Rowe 28..Soulh %';irmuulh. NIA 111664
bus-398-2231 e%l. 261 Fit% s08-39H.11836 Date Issued
Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSMFRAT70N
-mame"Appiwant Town of Yarmouth Water Dept. 508-771-7921
Sired Addrew 99 Buck Island Road
Ch1frown West Yarmouth I
MA i ZIP 02673
Name of Excavator (irdifrerent from applicant) I Phone
Street Address Town of Yarmouth Water Dept. 508-771-7921
99 Buck Island Road
West Yarmouth 1 0;,673
Name of OwnerHl pf Ptorty�Pe/rT� O /' Phan CCU
Street Address
%rl ,
oa 6a
Lownprtoo, toca000 Gnu purpose dx proposso trencat -
Plesse describe the exact location of the proposed bawls and its purpose Iinelude a description of what L for Is intended) to
be laid In proposed trench tell: plpaJeabl�)1
ee Ilan etc -)Please use reverse side iittpad�ditionaall space Is needed.
insurance cenrncate e:
• Town of Yarmouth -self insured
Name and Comet Inforrnallon of Insurer:
Pam Barnes - 508-398-2231 ext.:1270
Utz isle I: 2o / 1/
Name of I'umpeteno PPerrwa ias defined by S20C31R 7.0t: —{I
1 of
Meewdtuww HdeUeFL' # Ryan Holmes - 050786 exp.:6/15/2012
John Lang - 077585 exp.:8/30/2011"
Lkeow Grades Li 'ration Dote:
BY SIGNING IBIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMMLUI WITH. OR BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR
WML ALL LAWS AND REGULATIONS APPLICABLE TO WORK. PROPOSED, INCLUDING OSHA REGULATIONS,
G.L. a 82A, S2! CMR 7.01 d aq, AND ANY APPLICABLE • MUNICIPAL ORDINANCZ& BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWTFH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORUM THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER. AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
RIi WURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WTIN THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT. INSPECTIONS MADE TO ASSURE comnJANCE THEREWITH, AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALr Y.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOI MY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMUSS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EM ENNSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LOBS; OR DAMAGE TO ANY PFMSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE (IF DITh'ERENT)
DATE
OWNER'S SIGNATURE (IF DIFFERENT)
DATEt
2 of 2
6CRVICE NO.
.9neF + Sandt
NAME 3/�HI�/�yO JD���i7d//h/7If/ n'7o+e-
STREET , /J�O(19�y/1-,/�%'�•i�% �,C�
VILLAGE SOVQ/S
METER NO.. 1 r1 227 Q L/L/ ri
ComOwnweaR of %/%aedac eifd Official Use Only
.-_ Permit No. 60D— 11/
06
�[Jepar�menf o`.tirr Jirvice!
Occupancy and Fee Checked f� .
BOARD OF FIRE PREVENTION REGULATIONS ev.1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00
(P. LEASE PRINT IN INK OR TYPE ALL INFORMATION Date: O 6 — 02•t — aE
City or Town of. '/A V—m 0 y1- t+ To the Inspector of Wires: a '�
s application the undersigned gives notice of his or her intention to perform the electrical work described bel
Loc� an (Street& Number) 23-3- S. SAUC.E D12, S. YAarnOU—N
or Tenant
Telephone No.
�Is Address
Ln o N Es s permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
ikose of Building Utility Authorization No.
exi ing Service Amps / Volts Overhead ❑ Undgrd ❑
Net► Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: FIX six ROOmS W I tzt O Gr' 6ox8S / sec 7»etEJ
C 40 MC H�.r, 644—)* F+4N 0 Cf'14L — O uZA)
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
o. o ota
Transformers KVA
No, of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool ove n-
g rnd. ❑ rnd. ❑
o. o mergency g ng
Batte Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. o Detection an
Inittatin Devices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
eat Pump
Totals:
Number
ons
o. oSelf-Contained
Detection/Alertln Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal[I Other
Connection
No. of Dryers
Heating Appliances KW
ecur ty ystems:"
No. of Devices or Equivalent
N o. o Water KW
Heaters
o. o o. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Ilydromassage Bathtubs
No. of M1lotors Total HP
a ecommun cat ons rmg:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired or as required by the Inspector of Wires.
(V Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 06- 03 - O$ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
u ersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
_CHECK ONE: INSURANCE J& BOND ❑ OTHER ❑ (Specify:)
�I cert fy, under the pains and penalties of perjury, that the information on this ap licarlon is true and complete.
O 4FIRMNAME: t'i=S— PETs2tO.c�.L'�eCT2rC�AN LIC.NO.: I
N Licensee: _Pc7�ts.r7ti sIL-v.- Signature s� LIC. NO.: 11 0 03 — 6
\ , &I
(1f applicable, enter "exempt" in the license number line.) Bus. Tel. No.:
Ali \ddress:Alt. Tel. No.:
'Per h1.G.L. c. 147, s. 57-61, security work requires Department of Public Safety"S" License: Lic. No.
tZ 3 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
fl,\5
equired by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent Signature Telephone No. PERMIT FEE: S
n
FILE P,0PY
MOTEL HISTORICAL REVIEW NOTES a/o March 2008
Address: 277 South Shore Drive
Motel Name: Surf & Sand Beach Motel
No. of Units: CI: 36 Census Report: 36
Comments: 1 Manager's unit Constructed 1955
Board of Appeals Decisions
Petition No.
Date
Relevant Information Recap
199
3/6/52
Building Motel
231
10/16/52
transfer owner —right to build
587
9/6/62
add rooms # unknown
3252
12/27/95
zoning appeal of Bld. Inspect Re
assessory uses permitted
36 units on Cl since 3/27/75
General Comments
277
-
1
i
i
I
X-v_
- -I ir
F- -- -
Town of Yarmouth
2008 Motel Census
This form must be returned
with application.
Directions: Please complete the form below noting the number of guest units and bedrooms associated with those guest units in
each of the categories noted. Each unit should be counted in ONLY one (1) cateory. This Information will be used by the Board of
Health in their consideration of your application fora Motel License and for tracking purposes. This Information may also be used
by the Building Commissioner where non -transient rentals are Identified The relevant definitions are provided below. Please
complete the form using Information that best describes your general business practices.
• =
F
s -- {
NOV 2 8 2007
I
TypeofMotalUnIt
Standard
Efficiency
Cotta qes/Cabins
Type of Rental
# Units
# Bedrooms
# Units
# Bedrooms
# Units
# Bedrooms
Short-term (Transient)
Long-term (Public- NOT OWN
EMPLOYEES)
Owners Employees -
Permanent
Owner's Employees -
Temporary/Seasonal
Total
I hereby aGuiiowledge that the
time of submittal. . 1.
Owner's
Building Departments' ostamunauon ww De Dasea on Ve imonnauon provxm oy me comer at uhe
'Date: //-2 2'6 %
NOTES: lI_I_ R �(.� •M r N/� v h ►T /Vd l,
Type of Motel unit: h C.,tv �'"'S d uwt O K
Standard motel units provide occupants with a place to sleep and bathe. Kitchen facilities other than a microwave are not provided.
Efficiency Units provide occupants with a place to sleep and bathe, as well as kitchen facilities. Kitchen facilities may be either a cooldop or a
full stove. Efficiency units are generally contained within structures commonly recognized as motels, Le. comprised of 6 or more continguous
units., Efficiency units may contain one or more bedrooms.
Cottages/Cabinz are detached structures that provide occupants with. a place to sleep and bathe as well as kitchen facilities. CabuWcottages
may contain one or more bedrooms.
Type of Rental:
Short -tern (Transient) rentals are those rentals. considered temporary and short-term as defined by the Yarmouth Zoning Bylaw (see below).
Long -tarn Public rentals are those rentals made to the general public for periods of time that cumulatively, or in and of themselves, are
outside of the definition of transient
Permanent Employee rentals are those rentals trade for the purpose of providing housing to the owner's employees on a long-term. basis.
Seasonal Employee rentals are those rentals made for the purpose of providing housing to the owner's employees for the summer season
.:•(June-september).
Definitions:
Guest Unit A room or suite of rooms in a hotel, motel, motor inn or guesthouse, suitable for separate rental
Transient: For the purposes of the Gmitatiotns of motel or hotel use. Transient occupancy shall be limited to the temporary and short tern
occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have, and be able to demonstrate that
they maintain, a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than
thirty (30) days, and an aggregate of not.more than ninety (90) days within any six (6) month period. Use of a guest unit as a residence, or
dwelling unit, shag not be considered transient
For Office Use Only:
Zoning Determination Needed No Yes
License Issued No Yes License #:
Property Location:277 SOUTH SHORE DR
Vision I1):3333 Account # 0326800
MAP ID: 26/ 127/ / /
Bldg li: 1 of 1
Bldg Name: State Use:3010
Sec #: 1 of 1 Card 1 of 1 Print Date: 04/18/200812:33
815
YARM0UTH, ALA
IGIOVANNI, SILVIO V
OBOX 370
OUTH YARMOUTH, MA 02664
ddidonal Owners:
vel blic Water
'onal
Description
Code
Appraised Value
Assessed Value
tic
raved
CONtNIERC.
OM LAND
ODLMERC
3010
3010
3010
78,900
I,S51,100
15 800
78,900
1,S51,100
15 800
SUPPLEMENTAL DATA
Other ID: 22/ TII9///
Subdivision 171
'GES
ETTER
NI„» LAN
AN
LUIILBE194
P CODE
IS ID: 3333
ASSOC PIDO
VISION
Total
1,645,8WI
1,645,800
RECORD OF OWNERSHIP
BR-VOUPAGE
SALE
DATE
qlu
v/1 I
SALE PRICE
V,C.
PREVIOUS
ASSESSMENTS
HISTOR
IGIOVANNI, SILVIO V
IGIOVANNI SILVIO V
308239
ON31/1983
1
I
0
Yr.
Code
Assessed Value
Yr. I
Code
Assessed Value
Yr.
Code
Assessed Value
2M
Z008
3010
3010
3010
78.9W
1,551,100
15,800 Z007
007
007
3010
3010
3010
75,900
1,525,100
2,800
006
2006
2006
3010
3010
3010
237,100
11501,000
2,800
Total:
1645 JIM
Total:
1 1603
Total:
1740 00
EXEMPTIONS
OTHER
ASSESSMENTS
This signature acknowledges a visit by a Data Collector or Assessor
Year
' e
escri Lion
Amaunt
Code
Description
Number
Amount
Comm./nt.
APPRAISED VALUE SUMMARY
Appraised Bldg. Value (Card)
Appraised XF (B) Value (Bldg)
Appraised OB (L) Value (Bldg)
Appraised Land Value (Bldg)
Special Land Value
Total Appraised Parcel Value
Valuation Method:
Adjustment:
78,700
200
15,800
11551,100
0
1,645,800
C
0
Throb
ASSESSING NEIGHBORHOOD
NBHD/ SUB
NBHD NAME
I STREET INDEX NAME
TRACING
BATCH
0000/A
NOTES
URF & SAND
LDG ANGLED
rU NC= I
UNITS
et Total Appraised Parcel Value
1,645,800
BUILDING
PERMIT RECORD
VISITI
CHANGE
HISTORY
Permit
ID
Issue Date
escri Lion
Amount
LSE. Dare
%Comp.
DateComp,
Comments
Date
Tve
Is
ID Cd
PurposelResult
08.1026
06.744
02464
087
0-VII/2008
11/25/2005
11/21/2001
02/12/1999
RP
SP
CM
CM
lepair
10011
mmercial
7offunercial
9,375
50,000
44,000
3,000
06/28I2007
04I20/2000
0
100
100
100
OV01/2007
01/01/2002
01/01/2000
STRIP & REROOF 10
INGROUNDPOOL
REROOF
REPLACE RAILING
S 6/28/2007
1/9/2006
4/20/2000
Ul/1991
GM BP
GM BP
GD 00
DB 00
3uildingPernit
Wilding Permit
ieasur+Listed
easur+Listed
LAND
LINE
VALUATION
SECTION
B
#
Use
Code
Use
Description
Zone
D
Frontage
Depth
Units
Unit
Price
I.Factor
S.A.
Acre
Disc
C. Factor
ST. idx
Ad'.
Notes- Ad'
Special Pricing
d'. Unit Price
Land Value
1
1
3010
3010
IOTELS M94
IOTELS M94
34.00
1.75
BL
AC
14,000.00
20,000.00
1.00
1.00
0
7
1.0000
1.0000
3.00
1.50
0000
0070
1.02 31TE
1.80 XCS
1.60AC/LOC
LND-LEECH F1
42,840.00
54,000.00
1,456,600
94500
Total Card Land
Units:i
1.751
ACI Parcel
Total Land Area:
6,230 SF Total Land Value
I,551,100
Property Is�catic6277 SOUTH SHORE DR
Vision ID:3333 Account # 0326800
MAP ID:26/ 127///
Bldg #:
Bldg Name: State Use:3010
1 of 1 Sec #: 1 of 1 Card 1 of I Print Date: 04118/200812:33
CONSTRUCTION
DETAIL
CONSTRUCTION
DETAIL
CONTINUED
Element
Cd.
Ch.
Description
Element
Cd
JUL
Pescription
OP(1366J
Lyle
9
Motel
Adel
94
mm/Ind
ST[168
de
DS
Average+20
PJ BM[46]
tones
3ccupancy
34
MIXED
USE
DK[23381
Code
Description
Percentage
terior Wall I
17
tucco Alasonry
or TO 34
3010
MOTELSM94
100
zterior Wall 2
342
wr
34 3
oof Structure
H
oof Cover
+G/Rubber
4
terior Wall 1
5
alMeet
2
COST/MARKET
VALUATION
terior Wall 2
168
j. Base Rate:
.60
terior Floor 1
14
t
tenor Floor 2
ection. RCN:
,967,617
FUS
ff3sl
eating Fuel
lectrie
et OtherAdj:
.00
BAS ASS
eplaceCo
7
UBM FB
eating Type
otAir-no Due
YB
955
q 16
C Type
2
eat Pump
Code
Bldg Use
W10
tOTELS A194
emo
Total Rooms
ear Remodeled
Total Bedrms
p `h
Total Baths
nctional Obslnc
0m
zteal Obslnc
st Trend Factor
Cat/AC
I
EAT/AC PKGS
tus
Co mete
%verall%Cond
eType
3
lASONRY
aths/Plumbing
2
VERAGE
pprais Val
&700
iling/Wall
EIL & WALLS
p % Ovr
. _ a* s•ti
oom&Tnns
2
VERAGE
pOvr Comment
rsc Imp Ovr76
•_ i'
1
Wall Height
-
Comn Wall
ise Imp Ovr Comment
ost to Cure Ovr
ost to Cure Ovr Comment
may,,; • .. .
.'?��'tir��►}" � }�
r ]
OB-OUTBUILDING & YARD ITEMS(L) / XF-BUIIAtNG
EXTRA FEATURES(B)
ode
IDescription
Sub
Sub Descrit
KJB
Units Unit Price
Yr iGde
12y Rt
Cnd
%Cnd_4
rValue
GN3
WANT LIGHT
L
22 jpJ7.00
965
ATl
PATIO-AVG
200250
965
,000
800
y
PL3
UNITE
777AAA 00
006
100
3,000
''? — - r: -
.. -
L3
2 STORY CH
.00
1981
1
90
200
447
BUILDING
SUB -AREA
SUMMARYSECTION
Code
escri tion
Livinr Area
10,389
Gross Area
10,389
E . Area
10,389
Unit Cost
84.60
Undeprec. Value
878,943
�' •''r„ "�=
rI u !
�'
AS
trst Floor
OP -
orch, Open, Finished
0
3,316
829
21.15
70,136
"t =
`� _ •�
a
US
pper Story, Finished
9,128
9,128
9,128
84.60
772,258'kk
a 1
ym
do
0
680
68
8.46
5,753
FBlase,
Semi -Finished
486
608
486
67.63
41,117
B11I
asement, Unfinished
0
9,781
1,956
16.92
165,484
"
ST
Utility,Storage, Unfinished
0
168
50
25.18
4,230
K
Wood
0
2,338
311
11,70
29,696
TrL Gross LLYLase Area:
20,0031
36,408
23,2571
1,967,6171t
l
L
as - 01
�77 So 6
1y
March 6 1952
TG:r,TT OF Y:'L"tP;iLUTII '
BOA1D OF APMEALS
No • 199
D'_CISION
This is an �xdrn,sinncxoF�Bs}tmen:
x•�e$:us3ngc�_vea�itx�ta: - ��
Petition for approval of: a variance
The Petitioner. requested pe m. it to.. bald.a h4te% ........
4i S ySe.t o. B. :R.
. . . . . . . . . : . . . . . . • . • • . . .
1 j .. • . • . . . • •• • • • • • • • • • • • • • • • • • • . • • • • . • • • . • . • • • • .'. .
l contrary to,tho zoning by-laws, in that..V4rasr4Bh 4.....
�gction-2, requires the approval of the Board of Appeals. -
L.embers of Board of *Appeals pre gent:
Pr6sent A
Elwin W. Coombs, Chairman H. Stuart Ryder, Associate
John E. Harris Thomas Matthews, Associate
Alexander Catto
Fred X An us
It aq:pearing thaf notice of said hearing has been given
by sending notice thereof to the Petitioner and all those
owners of property deemed by the Board to be affected
thereby, and that publi notice„o•f,'PLWA h�arina having
been ivon'by publicatN 'in the'Capb'G�od-Standard Times
on.........ua�..?33. 1g5z ... ............ i ... the ,hearing was
opened and held on the date first above viritten.
The folloviing appeared in favor of the Petition:
Daniel J. Fern, Representing the Hirschs .APQQ= c :
Z:r. Bluecher Mr. and Mrs. W. Lawrence Prince Edwin G. Romer
Mr. Skolnick Jack Culley Arnold T. Booth
Mr. Sias E. J. Particelli Mr. and Mrs. Hubert Glendon
The following a?geared in oi7osition to the Petition:
iompoadoac.
zlesson�for�Decisions-
Mr.& Mrs. Earle Fox
Helen MacKenzie
Myrtle Breed
Haydn Mason
/Elizabeth Hussey
L'I-mbers of -Board -present..
Mr. and Mrs. Herman G. Curtis
Helen.Lcaeaiwes G u ns a v I uS
Myrtle Mehaffey
Herbert Foster
Edward Ambrose
Theodore Frothingham
Nr. Gill
T-
0
page -2-
;2eason for Decision:
L.embers of Board Voting.
0
Elwin 11. Coombs Fred M. Angus
John E. Harris H. Stuart Ryder, Associate
Alexander Catto Thomas Matthews, Associate
(Unanimous in granting petition)
Therefore, the retition for &,.p,)rova1 is granted,
and we authorize a variance to.. Esther.R: Hirsch and..........
r�rRt.Hirsch.................................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
on the follovine conditions, viz:
Approval for a.Hotel.is granted on basis of plans and elevations
�...�
indicated and offered at the Hearing.
. . . . . . . . . . . . . . . . ... .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...........................................................
No permit issued until 15 days froze da e of decision.
f
dle i�k
Wl, l CA" _11,R'f'JTH
BDi.1P,D OF L13f uz
DTECIjION
October 16, 1952
Donald J. Marquis
NO. 231
This is an Appeal from decision of Selectmen
refusing permit to: Donald J. Marquis
,nc
The Fetitioner requested permit to...allow the. building of hotel on
....... .... ..... 0 ....... . .
South, Street. Bass. River asp granted. _ .c
to Esther & MorcT Hirsch under Appeal d199.
. •............... . ........... . .. .. ... 0 ...... 9 ............. ........ ,
v.... ... 0 ....... a ..... a .. a ... .
5cilers of lhard bl' Appears present:
"re - n'; A bawbc
Elwin Coombs Richard Robsham (substituting for` Cri)
Fred Angus Thomas Matthews (substituting for Lr"i&rvi,a,)'
Alexander Catto
It ;npaarinv that notice nf said hearing has been given by sending
notice thareof to the Ft ci.tinnev and all those uv-wra of prorerty
dee,and by the Board to be affec';ed th:reby, and that Fublic notice of
such hearing having been giv,;r. by publication in the Cape Cod Standard
P'me: or ...... ................
October 1, 1�52 ... ...v2 the hearing was opAner. and held
M, t:,e rA2to firs•'. abcve . e3 tten.
Th_ fcl-lc•.nx,- appea:cd in fsver of the F.'VWVP% x
Donald J. Marquis :,Preal:
A. H. Castonguay (representing Mr. Marquis)
Frank Williams Robert Johnson
Leonard Burch John Martin
Frank E. Riley Mrs. Marquis
Hubert Glendon
LV•
• 1�
n
The following appeared in opposition to th_c Petition:
Appeal:
None
Reason for Decision:
Pe:abers of Hoard Voting:
Elwin Coombs Alexander Catto
Fred Angus Thomas Matthews Richard Robsham. (Unanimous in granting Appeal)
T4erefore the is granted,
Appeal x5ei.coc
rasutbz -
Transfer of approval from former owner to new oiner.granted�.a.....,•
♦ .......... • • r e ... • . n ... D • . a ... • . ...... 0 .........
, . . . .. ... .. ... . . .. a I .. . ...... .... .. .... ... ..... ...... .. .. . .... .. .. . .. .
on the follswi-ig cordlitions, viz:
v , .. .. . ... 0 . , . .. ... . 1 . .. .. .....• .... , .. I . n < ... , ... , .. • • • .... . . .. . ... . e O ,
• . • f . ... .. a ) .. 1 . + .. . .. . . 7 1 .. • . ! O . • .. .. - . . . • I • . - . • , . , C , - G D ^ 4 O ^ O .. .
yo ne:rr t isRLel vitit fi.tPcn C-aya Lam da; e of d -clsi)n.
Filed frith ioun Clerk: OCT 8 10(v)
Petitioner: Donald Jo Ihrquis
, ti/47-t�-
TU.-. OF YALUJUTH
BOARD.OF AY;VdZ aZ % !
Hoarine Data: Soptenber 6, 1962
Petition I;umber: 5W
DIMIS1U.;
The petitioner requested the approval of the Board of -A moals to alloir the creation of :L4
units additional to the Surf & Sand Motel., Bass River, 'Lcscaaorrs I1apt Parcel T119,
I1=bers of Board of Appeals prosent:
Albert ?:ebb
A1cix. Catto
Stuart gydar
Paul Webber
Harrold L, Hayes, Jr,
It annoaring that notice of said hearing has been given ly Betiding notice thereof to the
potitioner and all those omere of property deemed by tht Board to be affected tharb�y
and that public notice of such hearing having been give:t by publication in the Cape Cod
Standard Times on August 1¢ & 230 1962, the hearing rras 3pened and hold oa the data first
above Witten.
The following appoarod in favor of tho petition:
Donald J. Iir uia
Sally I iquis
Leonard Burch
Cora Burch
Walter B. 11i]liams
Tha following appeared in opposition:
Ilona
Raascn for Decision: It appoared at the hearing that the request Bran far an addition to
tha oxicting Surf & Sand hotel located on South Shard Drlro in Bass River, It fuaLher
appzarcd that original plans called for the units requaLlod but t hay rare not built at the
of. original construction, The addition imuld be on tIw I6zturly aide of the o:dstin; mot
and :could be in keeping with the dociaicn of the proscat aotal structure.
It appeared that all the rcquironcnta of the zoning by6-la r wrould be rat including sot. -back
sideline roquiremant3, -It further appoarad there vas adijuato parldng to accas;odato addition,'_
gucatu at the potitionerls rotel location,
The board that the publio good uould not be advorsay affected by granting this pu.�it
aadly granted the request as sot forth in the poiltion.
HIambors of Board voting:
Albert '-.'*ebb — In favor
Alex Catto — In favor
Stuart Ryder e Infavor
Paul ;Iebbor - In favor
Harold Lo Hayes, Jr, — In favor
ThOrOissued M�5 th1petition for approv l is grantod on the folloring condit:
days from dato of decision. ionsIio perctit
Harold L. Hayou, Jr.,
Chairman
TOWN OF YARMOUTH
BOARD OF APPEALS
DECISION
FILED WITH TOWN CLERK: DEC 2 7 1995
PETITION NO: #3252
HEARING DATE: December 14, 1995
PETITIONER: Silvio V. DiGiovanni
c/o Philip E. Magnuson
255 Main St.
Hyannis MA 02601
PROPERTY: 277 South Shore Drive, South Yarmouth MA
Assessor's Map 22 Parcel T119
y Dtr., 27 Ptz C�o .
10WNCLi:itr, ir,L�>5l'i.i
MEMBERS OF THE BOARD PRESENT AND VOTING: Jerome Sullivan, Acting
Chairman, John Richards, James Robertson, Joseph Samosky, Andrew Ryan.
It- appearing that notice of the hearing has been given by sending notice to the petitioners and all
of those owners of property deemed to be affected thereby, and to the public by posting notice of
the hearing and published in The Register, the hearing was opened and held on the date stated
above.
Attorney Philip Magnuson presented the petition to the Board. Mr. Magnuson was accompanied
by Mr. Silvio DiGiovanni, the petitioner. Mr. DiGiovanni is the owner of the property in question
which is the site of the Surf and Sand Motel Resort. The Surf and Sand Motel is a pre-existing,
non -conforming motel which has been in operation for over 30 years. The locus consists of 3.35
acres with approximately 350' of shore line along Nantucket Sound. It is located in an R25 zone.
The petitioner requests to overturn the decision of the Building Inspector dated October 17,
1995, that aquatic recreational activities are not accessory uses to the existing motel use at the
Surf and Sand, or in the alternative a Special Permit to allow those aquatic recreational activities
including parasailing, banana boat rides, and wind surfing. These activities will be offered
primarily to motel guests but would also be available for incidental use by non -guests which will
include guests of motel customers. Any such non -guests will be required to register with the Surf
and Sand and receive a Registered Guest Pass to use their facilities. The petitioner will maintain
sufficient supervision so as to be sure that these activities do not interfere with or detract from the
principal motel uses. All of these activities will primarily take place out on the waters of
Nantucket Sound using the beach front only as a starting point. The pick up boats will come to
t
W�
the beach through a marked safety zone to pick up and discharge passengers. There will be no
on -premise sign advertising these activities and no increase in parking demand is anticipated.
No one in the audience appeared in favor of or in opposition to the petition.
The Board received correspondence from Forrest White, Building Inspector, referring to this
s. application and informing the Board members of a previous decision by the Chatham Zoning
Board of Appeals, a memo from the Planning Board, letters from two town residents in
opposition to this petition, and comments from Linda Sears, Recreation Director for the Town of
Yarmouth with respect to concerns for the safety of swimmers in the public beach area and
requesting marked access lanes for the boats used to pick up and discharge passengers at the Surf
and Sand beach area.
The Board was satisfied that granting the requested Special Permit will not create any undue
nuisance, hazard, or congestion, and that there will be no substantial harm to the established or
future character of the neighborhood nor of the town. There was general agreement that such
activities would be an allowed use, incidental to the principal motel use.
Accordingly, after further deliberations, a Motion was made by Mr. Robertson, seconded by Mr.
Ryan, to overturn the decision of the Building Inspector regarding the accessory use and such
Motion finds as an accessory use permitted by the by-law the three activities requested (i.e..
parasailing, wind surfing, and banana boat rides) and to be permitted accessory uses to the
primary use of the property which is a waterfront motel, including their incidental use by
registered day -guests. The vote was Mr. Sullivan, Mr. Robertson, Mr. Richards, Mr. Sarnosky,
and Mr. Ryan in favor. The vote was unanimous.
Appeals from this decision shall be made pursuant to c40A §17 and must be filed within 20 days
after the filing of this noticeldecision with the Town Clerk.
Special Permits shall lapse if a substantial use thereof or construction has not begun, except for
good cause, within 24 months of Special permit approval (exclusive of time required to pursue or
await the determination of an appeal referred to in MGL c40A §17, as amended) from the grant
thereof.
a r TOWN OF YARMOUTH Building Department BUILDING
(508) 398-2231 ext.261
PERMIT NO 4'6.08-1293
;K ISSUE DATE :::5%7%2008:: ; PROPOSED USE ;_ ......... PERMIT
APPLICANT Joseph Butler
"......---- JOB WEATHER CARD
Joseph
Butler .
PERMIT TO Alterations
AT (LOCATION) 10277SOUTH SHORE DR ZONING D RIC 25 Bldg. Type: Commercial
SUBDIVISION MAP LOT BLOCK 1026.127 BUILDING IS TO BE: CONST TYPE 6-B USE GROUP R-1
LOT SIZE O
CONTRACTOR
Surf and Sand Motel - replace existing kitchen area 8 bathrooms In six units - new sheetrock, flooring, LICENSE 071488
REMARKS tile, Insulation in ceilings as per plans submitted 04/24/08.
Butler, Joseph
ns POB 616
AREA (SO FT) EST COST ($ $43,700.00 PER ($) $240.00 South Dennis MA 02660
5087903899
OWNER IDIGIOVANNI, SILVIO V BUILDING DEPT BY
ADDRESS P.O. Box370
South Yarmouth MA 02664 PHONE 6174840779
INSPECTION RECORD FIELD COPY
Date - - Note Press - Corrections and RemArks Insoector
3d- dy
a
or ��
TOWN OF YARMOUTH
Building Department
BUILDING
_ _ ,
PERMIT NO
(508) 398-2231 ext.261
=
PERMIT
��•.
ISSUE DATE 0/31/2008 ; PROPOSED
USE
•� ,
APPLICANT Leif Boucher ---------- ......-'
JOB WEATHER CARD
_
PERMIT TO Repair
AT (LOCATION) 10277SOUTH
ZONING DISTRICT R-25
Bldg. Type: Commercial
SHORE DR
SUBDIVISION MAP LOT BLOCK 1026.127 BUILDING IS TO BE: CONST TYPE = USE GROUP =
LOT SIZE
REMARKS remove & replace rubber roof.
AREA (SO FT) EST COST ($)I$t0,000.00 PERMIT FEE ($) $75.00
OWNER IDIGIOVANNI, SILVIO V BUILDING DEPT BY
ADDRESS IP.O.Box370
South Yarmouth MA 02664
101, a [41►I:1;110191 ;
CONTRACTOR
LICENSE 076085
Bottcher, Leif
825 Cedar Street
West Bamstable MA 02668
7748360180
PHONE 15083989556
FIELD COPY --
Date I „ Npte Progress - Corrections and Remarks I Inspector
SHEDS LESS THAN 150 SO. FT. SHALL
BE PLACED A MINIMUM OF 30 FEET
FROM THE FRONT LOT LINE AND A
MINIMUM OF 6 FEET FROM SIDES AND
REAR LOT LINES.
Permit � Vi
Fee S I_-�u tRr
Permit expiry 6 non from
issue date.
'SS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
OCT g 1 200a 1146 Route 28
South Yarmouth, MA 02664
ING (508) 398-2231 Ext. 261
CONSTR 3y N ADDRESS: s�nrY ale I t��. �{„ Vr1 rn all MAr
ASSESSOR'S INFORMATION:
Map: Parcel: %Z
OWNER Ewrl lA�4V nn► �i7n rM 1t�5DB-.3AB -g55(a
NAME PRESENTADDRESS TEL #
�8-�{o2-liZ(cZ
CONTRACTOR: L6F' &Jt har 5 Cedar _W_ 1-nS nhl n pZi���3
NAME MAILING ADDRESS TEL#
❑ Residential Commercial Est Cost of Construction S I P n n o• d o
I lome Improvement Contractor Lic. # I I I Gi 5 n Construction Supervisor Lic. # 0-7U b 8 c5
Workman's Compensation Insurance: (chock one)
❑ I am the homeowner ❑ I am the sole proprietor 1f I have Worker's Compensation Insurance
x 1J,
Insurance Company Name: II 1 1(An Worker's Comp. Policy# l Aw�!o!'���
WORK TO BE PERFORMED
0 Tent (Fire Retardant Certificate attached)
Duration Wood Stove Shed
0 Siding: # of Squares ❑ Replacement windows: #
0 Replacement doors: #
Q/Re-roof. �b. pJ' QQpQ
() Stripping old shingles' () going ova layers of existing roof
'The debris will be disposed
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belicL I understand that any false answers)
will be just cause for denial or revoct i�f my license and for prosecution under M.G.L. Ch. 268, Section 1.
Applicant's
Owners Signature
Approved By: Date:
Building Official (or designee)
Zoning District: R2 J
Historical District: ❑ Yes pC No Flood Plain Zone: Yes 0 No
Water Resource Protection District: Within 00 fl. of Wetlands:
❑ Yes , 1�No ) Yes ❑ No
3101
1'Ire commonwealth of massaenuseas
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual):
Address: 932 9 0 f d (-r
City/State/Zip:W. M.M MA- 62bkoQ Phone -3ko2-42(p2_
Are you an employer? Check the appropriate box:
1.o I am a employer with *5 4. ❑ I am a general contractor and I
errmlovees (full and/or hart-time).0 have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
listed on the attached sheet
These sub -contractors have
employees and have workers'
comp. insurance.t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
I LEI Plumbing repairs or additions
12.MRoof repairs
13.❑ Other
Any applicant that checks box # 1 must also fill out the section below showing their worker' compamtion policy information.
t Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractors trout submit a new affidavit indicating such
tContractor 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 subcontractors 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. C
Insurance Company Name: ► fl r �l 1I IIy&n
Policy # or Self -ins. Lic. #:U%I3b,'5142_O hi lei- Expiration Date: %—
Job Site A d�a: StXC L;sand M c4e _1 City/State/Zip: S. V(1,1"M D IJ ) H4 02-61,�L
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 S 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.
1 do hereby certify under 14r4ains anApenylties of perjury that the information provided above is true and correct
Phone #: Sp;,—;3Lo2-_g2Lo2
use only. uo not write in arts area, to
City or Town:
or town official,
Permit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
11 Contact Person: Phone #: 1I
0
From: Erin Govonl To: Leif Botcher Uale: }N.NN[VUO I nne: Iru4:Ut I M �•Ma
HightNaX C3-1 y/3/2008 4:5'l:4Z AM YAUE 3/0U3 Fax Server
ACORD. CERTIFICATE OF INSURANCE DATE(MWDD1YY) 09-03-08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
BRYDEY k SUII.IVAN INS AG HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
88 FAIMOLMI RD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
IiYANNIS, MA 02601
232MY
INSURED
LEF BOTTCIIFR IIOME
BMPROVfiMFNT INC.
825 CEDAR STREET
WYSTBARN STABIE,MA C2668
COMPANY
A TRAVELERS DIRECT ASSIGNMENT
COMPANY
B
COMPANY
C
COMPANY
D
COVERAGE
TWS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REOIAREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAYBE ISSUED OR
MAY FERTAIN THE INSURANCE AFFORD ED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICES.
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAWS,
CO POLICY EFF POUCYEXP
LTR TYPE OF INSURANCE POLICYNUMBER DATE(MMDD,YY) DATE LIMITS
GENERALUAENUTV GENERAL AGGREGATE 3
COMMERCIAL GENERAL PRODUCTS-COMPIOP AGG. $
CLAIMS MADE OCCUR. PERSONAL AA ADV. WURY 3
MYNER5 AA CONTRACTORS PROT. EACHOCCURRENCE $
FIRE DAMAGE (Any one lire) S
MED. EXPENSE (Any One person) $
AU70LAOSILE LIABILITY
ANY AUTO
ALLOWNED AUTOS
SCHEDULE AUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE UABILTIY
ANY AUTOS
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UL42RELLA FORM
WORKERS COMPENSATION AND
A EMPOLYER'S LIABILITY UB-0407M863-08 07.30-08
THE PROPRICTORI
PARTNERSIEXECUTIVE X NCL
OFFICERSARE: EXCL
OTHER
COMBINED SINGLE LIMIT $
BODILY WURY(Par Person) $
BODILY MURY(Per AvWere) f
PROPERTY DAMAGE 3
AUTO ONLY- LA ACCIDEM f
OTHER THAN AUTO ONLY:
EACH ACCIDENT S
AGREGATE 3
EACHOCCURRENCE S
AGGREGATE S
07.30-09 STATUTORY LIMITS X
EACHACCIDENT S 100.000
DISEASE-POLICYLMIT $ 500,000
DISEASE -EACH EMPLOYEE S 100.000
DESCRPTION OF OPERATIONSILOCATK)NSVEHK:LESIRESTRICTIONSISPECIAL ITEMS
THIS REPLACES ANY PRIOR CETMCATE ISSUED TO THE CIRTIRCATE HOLDER AEFIECITNG WORIZRS COMP COVERAGE -
CERTIFICATE HOLDER
ACORD 255 (3193)
CANCELLATION
SHOULD ANY OF THE ABOVE CESCRGD POLICIES BE CANC131 BEFORE TIE
EMRATN]N DATE THEREOF. V C GSUNo COMPANY WILL ENDEAVOR TO MAIL 10
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER MIMED TO THE LEFT, BUT
FAILME TO MAIL SUCH NOTICL SHALL IMPOSE NO OQMsATNJN OR LIABILITY OF
ANY NANO UPOV THE COMPANY, ITS AGENTS OR REPRESENTATIVES
AUTHORIZED REPRESENTATIVE
Charles J Clark
uoACOlzUUO JL:OL fulDtili5y5/ VIVINUILIU LiMJUN PAGE 03/03
ACO D,M CERTIFICATE OF LIABILITY INSURANCE
°"TE'8/2 0
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Divirgilio Insurance Agency,
ONLY AND CONFERS NO FOGHTS UPON TEHTE�CERTIFICATE
HOLDEREXTEND OR
270 Broadway
THE COVERAGE AFFORDED BY THE POLICIES DaOW.
P.O. Box 8065
Lynn, MA 01904
INSUR6ISAFFORDING COVERAGE
NAILS
INSURED
NSURERk Westarn World
LEIF BOTTCIIER HOME
NGURER B: -
IMPROVEMENTS INC
NGURERC:
625 CEDAR ST
IH3URF.Ro- '
WEST BARNSxABLE, MA 02668
NsuREaE:
COVE RAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVI¢ KEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, PERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EVLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS.
POLICYNUM13CR
POLICY EFFECTIVE
POIICYDCPIPATON
LIMITS
A
GENER&LIA ILLY
COMMERC1ALOENERALLVIBAlLY
tba
8/27/OB
8/27/09
PA04OCCURWNCE
s 000 000
= 000 ODO
TOI&NTED
S9316A0aalm
HO)IXP aro eoail
CLAMS MADE EXI OCCUR
$ 1,000.OU�
PERSOWLAADVNJUiY
s 1.000.000
GETCRALA0EA83JWE
s 50.000.
GEN'LADOREOATEUMITAPP
UFM
PRODUCTS-COAPOPAGG
S 5.000
vOLICY j
PRo toe
AUTOMOMLE
LIABILITY
ANYAUTO
CCMDNrDGNCLEL1MIt
DOOLYNJLRY
I�PQsW
s
ALL ONNED AUTO$
SCHEDULEDAUTOS
BOOILYNARY
(RYacddrt)
S
HIREDAUTOS
NON4)VJNEDAUTO3
FREPERTYOAMATE
(FW mcd dX/)
_
GARAGE LIABILITY
AJIMONLY-EAACCDEIT
s
OTW.RTHAN EA ACC
AUmO LY:. A.GG
A
ANYAUTO
s
EXCESWmand.LA LIABILITY
EACH 000 L.R IENCE
s
OCCUR CLAMS MADE
f
•—
f
DEDUCTIBLE
%6T Ju O H•
s
'
RETENTION s
WORKERS COMPENSATION AND
EL FACHAGO°ENT
s
DIPLOYOWLIA°ILITY
EL DISEASE -FA ELOLOAEE
s
ANY PROPRIETOR/PARTNERIEXECUTIVE
OyyfP�FeIICER/MEMDER EXCLUDED?
.
ELDISEA!E-POUCYLMIT
s
BPEtme 30VI Kx+
OTHER
DE30RIPTIONOFOPDTATIONSILACATIWS IVa CLE=IEXCL1J3IW3 ADDED DYFNDORSENENTI SPECIAL PROVISION$
Carpentry- roofer
fax 508-171-0384
SHOULD ANY OF THE ABOVE DESCRIBED POIJ= DE CANCELLED 13EFORETHE EXPIRAT;ON
DATE THERCOF, THE MSUINO.INSURER WILL ENDEAVOR TO MA;L 0 DAYS W RMC"
NORCE TO THE CCRMCATC HOLDER NAMED TO THE LEFT, BUT FAIW RE TO 00 s0 SHALT
LAP= NO 08UCATON OR LIABILITY OF ANY KIND UPON THE INSUREK ITS AGENT'S OR
RFPRESENTAMVE
E1
ACORO25(2001108)
6 Board o(ilmldigg Aegulations and Stap4ards
:` a �onslrltgtron,SupervisQrllgge '
7$085 , �•TJ 1
r 1a o xp �tLon: 13 Q49 To .41Z4
Ll=IF E BOTTCHEI� '0.
t ,:' -
o r 825 CEDAR STREET , S:W7--.e- �c
W BARNSTABLE, MA 02668 omgpissinuer-------------
Board of Building Rrgulalions and Standards
HOME IMPROVEMENT CONTRACTOR
RegWration 111950
FAc`�iratig- 118/7rg09 Tr# 127890
LEIF BOTTCHER Hg1AL=4MP r,4NTRACTOR
LEIF BOTTCHER
825 CEDAR ST
W. BARNSWI E, MA 02668 Administrator
9
w r TOWN OF YARMOUTH Building Department B U I L D I N
+ (508) 398-2231 ext.261
PERMIT NO B-08-1390-
•. ISSUE DATE 5/29/2008 . ; PROPOSED USE :::::::: PERMI;
APPLICANT 'BrianWarbuRon ; JOB WEATHER CARD
.............................
PERMIT TO Aceessory Structure
AT (LOCATION) 10277SOUTH SHORE DR ZONING DISTRIC R-25 Bldg. Type: CommerGal
SUBDIVISION MAP LOT BLOCK 026.127 BUILDING IS TO BE: CONST TYPE 5-5USE GROUP R-4
LOT SIZE 7--�
Shed - 10 x 14
REMARKS
AREA (SO FT) EST COST ($ 1$3,
OWNER IDIGIOVANNI. SILVIO V
ADDRESS 0277 SOUTH SHORE DR
SOUTH YARMOUTH I MA 102664
PERMIT FEE ($)
BUILDING DEPT BY
INSPECTION RECORD
CONTRACTOR
LICENSE 062056
Warburton, Brian
235 Great Western Road
South Dennis MA 02660
5083981900
PHONE 16177999199
FIELD COPY
Date Note Progress - Corrections and Remarks Inspector
(-&LoP (.. "`_ AA,
n
TOWNS OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 261 Fax 508-398-0836
Inspection and License Report
� I G
CAL
G
ZONING
SIGN CODE
Address 711 f u •1 1z /^ < < ✓�. Business Name f l,� /
Date of Inspection 7 Contact Zzo-6-Ile6 Phone
During the annual inspection of your premises, performed in accordance with the provisions of Section 106 of 780 CAIR (bfassachusetts State Building
Code), the Board of Selectmen and/or the Board of Health rules, the following violation (s) were observed:
);mess -'
❑ Emergency egress signage Location
L+
❑ Emergency egress lighting
Location
❑ Egress door hardware
I/ocption
n
tl
,
❑ Maintenance of exits
Location
_
❑ Guards/Handrails
Location
Mechanical
❑ Combustion Air
Location
❑ Vents
Location
❑ Storage in boiler rooms
Location
B Z' O
y y
d g
❑ Automatic door closures
Location
(
r
d �' p
on boiler room doors
Smoke Detectors
Other
MIT.A.1.._
Location
Location
Ir
0,9
e
t//�: •� `. Y,/I//-rr ).�•.�/ Irk rIo// �.-� � rh.-J (�/t % l% C �1
� t
71t
780 CDiR Section 103 MAINTENANCE provides that the owner, as defined in 780 ChIR Chapter 2, shall be responsible for proper maintenance.
In order to abate the above violation(s) you must:
❑Macke corrections immediately and contact this office for a follow-up inspection.
L7/Make corrections within / 0 days and contact this office for a follow-up inspection.
Local Official Inspector ��� %����� • i�%i/���
Fyn J
Received By: 0 r / . i i kl Title
Rev. 3/03 Original -Premises Yellow -Building Department Pink -Licensing Authority
RECEIVED
0 1Qb C+�S
MAY 2 9 2008
BUILDING DEPT..
By:
vrrrce use uary
SHEDS LESS THAN 150 SQ. FT SHALL
Perald_(-
CE PLACED A P"I"JI :"U ", OF 30 FEET
FROPt1 THE FRONT LOT LINE AND A
���
Fee $aQ •Q
h91NI1`1UM OF 6 FEET FROM SIDES AND
permit expires6
REAR LOT LINE&
issue date.
BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261
CONSTRUCTION ADDRESS: Z71 Soym! StInaF PvLryti
ASSESSOR'S INFORMATION:
Map: 24 Parcel: l z7
OWNER: (Zone=, SAno ,rAorbt Z77 Se�M (Qry.ae 172ryd' 6r)-79cl-eitga
N PRESENT ADDRESS TEL #
Sic}-L-1 SFien
CONTRACTOR S %.Li.4.d ijJ�.'Q,,.c,'ovr S55 Cr2 wt-SMtN rZ-t-) Sovrti Drtv..ret. PAA Sa8
NAME MAILING ADDRESS
❑ Residential &<ommercial Est. cost of construction $ 3 t 53
Horne Improvement Contractor Lic. # ►'i V(5,7 construction Supervisor Lie. # 6 to -4051-
Workman's Compensation Insurance: (check one)
❑ I am the homeowner grl am the sole proprietor ❑ I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp. Policy#
WORK TO BE PERFORMED
0 Tent (Fire Retardant Certificate attached)
Duration Wood Stove Shed 10114
❑ Siding: # of Squares 0 Replacement windows: #
0 Replacement doors: #
❑ Re -roof # of Squares
() Snipping old shingles' () going ova layers of existing roof
'The debris will be disposed of at
Location of Facility
I declare under penalties of perjury that the statements herein contained no true and correct to the bat of my Imowkdge and belief. I umdastaod tbat any false answer($)
will be just cause for denial or revocation of iccnsc and for prosecution under MG.L Ch. 268, Section 1.
Applicant's Signature: Date:-9-7-A-o'7
Owners Signature (or anachmeot) Date:
Approved
KQC
al (or
Zoning District: g a s .
Historical District: ❑ Yes 6 No
Water Resource Protection District:
❑ Yes )ioNo
Date:
Flood Plain Zone: 16 Yeses No
Within 19(1 R. of Wetlands:
ja' Yes ❑ No
3101
• The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeib�l r�
Name (Business/OrganizatioMndividual): 'Ren&I �1 n .2 rnrJ
Address: -2i S urn m-, L, xOMwul ,to
City/State/Zip: So,iM 12ny"K, A,ir] Phone#: W-3ye/2P7
Are you an employer? Check the appropriate box:
❑ am a g 4. I general contractor and I
1. ❑ 1 am a employer with A.I.— ub-c
oyees (full and/or part-time)!
2. I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.)
3. ❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.) t
have hire s ontrac n
listed on the attached sheet.
These sub -contractors have
employees and have Workers'
comp. insurance.t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MOL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other,
'My applicant that chucks box # 1 must also fill out the section bclow showing their workers'compensation policy information.
t Homeowners who subrnit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConbutors that click this box mat attached an additional sheet showing the name of the sub-conttactots and state whether or not those entities have
employees. If the sub -contractors have employees, they mat provide their workers' conip. policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below Is the policy and Jab site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: 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 MOL c. 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 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
1 do hereby certify under t e pains and penalties of perjury that the information provided above is true and correct
e;o.,,n,��•�/ Date:
Phone i, S•s `3,?,9—/ pda
official use only. Do not wri
City or Town:
area, to he completed y city or town official,
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for, the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cant' workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self -insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Revised 11-22-06 Fax # 617-727-7749
www.mass.gov/dia
PLOT PLAN
FOR LOT #
Z�r — (2-7 ,
lhdicate locatLon cf garage or accessory building
Additions with dashed lines -------------------
sewerage A (cemPca)
i
I I
I(lot................ft. rear) I
r,
butt ='s
Me
of #
! this is a
=new late
rite In name
stseet-
SIDE YARD
REAR YARD
........,...eft.
I
SET CK
.:see .eft.
I
.Q,
(lot•...e.•....•..•...fto f ontage)
SMZ YARD
S-111 �&oni prtivF —
(NAME OF STREET) �•
Diformatiron
SunnUad by
Salt Spray Sheds
Estimate
235 Great Western Road
South Dennis, MA 02660
Name / Address
Surf and Sand Motel
277 South Shorc Drive
South Yarmouth, Ma
617-799-9199 Cell
Ship To
Terms Project
Date
Estimate #
5/14/2008
615
Description
Qty
Rate
Total
IOx14 Even Pitch Shed
1
3,000.00
3,000.00
Standard 3' Board and batten Door
1
0.00
No Windows
1
-38.00
-38.00
6' Board & Batten Double Door .
1
191.00
191.00
Total $3,153.00
Signature 0
Phone #
Fax #
E-mail
Web Site
508-398-1900
508-398-1995
saltsprayshedsoacomcast.nct
www.salLspraysheds.com
kU
J
igy KpFtE¢5
Z•d•a
_- kr4 roe P(A
`�tiv P�3r
2Yb F'r r-tvwz FMA"6 16" ON 4
i UI
�li,]
F, -
j
14, . a.,
i
0-- 3— 1 3, n• itet, e L
to
This Section for Office Use Only
Building Permit Number:
Date Issued:
Signature:
Certificate Occupancy
Building O real Date(
is Is not required
Section 1 - Site Information
1.1 Property Address: 1.2 Zoning Information:
air Sours, SAW JTF.r 1,e
Zoning District Proposed Use
1.3 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
lgFS b'l ma's a2Lb fi/�
1.4 Water Supply ( M.G.L. c. 40. S 54) 1.5 Flood Zone Information: Comments:
Public X Private Zone: BFE:
1 of 4
OVER
3.2 Registered Home Improvement Contractor.
Com any Nam
`1 osao ,
Not Applicable ❑
Registration Number
i a 7
—ter—
Address
-Q ok C I C S rh►S JtIA+ 44- 164S�
Expiration Date
i2
Signatu riTelephone
Sectio -Workers' Compensation Insurance Affidavit (MAL c. 152 S 25C (6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the de 'al of the issuance of the building permit.
Signed Affidavit Attached Yes .......... No ..........
Section 5 - Professional Design and Construction Services - for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116 (containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect:
Not Applicable
Name (Registrant):
Registration Number
Address
Signature Telephone
Expiration Date
Section 5.2 Registered Professional Engineer(s)
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Section 5.3 General Contractor
Not Applicable ❑
Company Name
Person Responsible for Construction
Address
Signature Telephone
2of4
TOWN OF YARMOUTH
(�fj Building Department
Town Hail
Yarmouth, MA 02664
(508) 398.2231 ext.261
BUILDING PERMIT
TRANSMITTAL
Temp Permit No.:
T-08-445
Applicant Name:
Joseph Butler
Applicant Phone:
5087903899
Building Location:
0277 SOUTH SHORE DR
Owner's Name:
DIGIOVANNI, SILVIO V
Owner's Addres
P.O. Box 370
South Yarmouth MA 02664
Owner's Telephone:
(617) 484-0779
(OFFICE USE ONLY
Recorded By:
IC
Permit Fee:
$0.00
Deposit Rec:
$25.00
Payment Type:
Cash ChkNo.: 0
Net Owed:
($25.00)
Application Date: 4/24/2008
Issue Date:
Expiration Date
Comments: Map/Lot: 026.127
replace existing kitchen area & bathrooms in six
units - new sheetrock, flooring, tile, insulation in
ceilings
REVIEWED BY:
1. WATER DEPARTMENT:
DATE:
N/A:
2. ENGINEERING DEPARTMENT:
DATE:
WA:
3. CONSERVATION:
DATE:
N/A:
4. HEALTH DEPARTMENT:
DATE:
N/A:
5. BUILDING DEPARTMENT:
DATE:
N/A:
6. FIRE DEPARTMENT:
DATE:
N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY:
SIGNATURE OF APPLICANT:
DATE:
Date Printed: 5/6/2008
Section 6 - Description of Proposed Work (check all applicable)
New Construction ❑
I (for multiple family only) No. of Bedrooms
(for multiple family only) No. of Bathrooms �—
Existing Bldg. ❑
Repalr(s) ❑
Alterations ❑
Addition ❑
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work:
ki f e*% atu l a,0xn
e il h YAlye caL., oil gjti-di"e, vrt Y�on
Section 7 - Use Group and Construction Type
Building Use Group (Check as applicapable)
Construction Type
A ASSEMBLY
❑ A-1 ❑ A-2 ❑ A-3 ❑
A-4 ❑ A-5 ❑
1A ❑
1B ❑
B BUSINESS
❑
2A ❑
2B ❑
2C ❑
E EDUCATIONAL
❑
F FACTORY
❑ F-1 ❑ F-2 ❑
H HIGH HAZARD
❑
3A ❑
313 ❑
1 INSTITUTIONAL
❑ 1.1 ❑ 1.2 ❑ 1.3 ❑
M MERCHANTILE
❑
4 ❑
R RESIDENTIAL
❑ R-1 R-2 ❑ R-3 ❑
5A ❑
5B
S STORAGE
❑ S-1 ❑ S-2 ❑
U UTILITY
❑
SPECIFY:
SPECIFY:
SPECIFY:
M MIXED USE
❑
S SPECIALUSE
❑
Complete this section If existing building undergoing renovations, additions and/or change in use.
Existing Use Group:
Existing Hazard Index 780 CMR 34
Proposed Use Group: QT_
Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area
Building Area Existing (if applicable) Proposed
Number of floors or stories
Include basement levels
Floor Area per Floor (sf)
Total Area All Floors (sf)
Total Height (ft)
Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes .......... No ..........
SECTION 10a OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 D ijolt+0nr f , as Owner of the subject property,
hereby authorizeyh �• """Y� to act on
my behalf, in all /matters relative to work authorized by this building permit application.
V • / 1.1 _�L�f,;ry an.NA J//: S/D S'
Signature of Owner I IDate
----- ---- - --- ----------- �- — -----3 of_4----------------- ----- -- - OVER — - - -
SECTION 10b OWNER/ AUTHORIZED AGENT DECLARATION '
i, , as Owner/Authorized Agent
hereby declare that the statements and information on the forgoing application are true and acurate, to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent
Section 11 - ESTIMATED CONSTRUCTION
COSTS
Item
Estimated Cost (Dollars) to be
cmm�ieled by ne.mil enniln-.N
1. Building
aSa-m rz
2. Electrical
gyn. rD
3. Plumbing/Gas
-7 ja•
4. Mechanical (HVAC)
5. Fire Protection
SQ"a� rV
e.Total.(1+2+3+4+5)
/{ %n /1/
7. Total Square Ft. Oa new structures s aaNeanl
Check Below
❑ Conservation•Commisslon Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
Date
4of4
TOWN OF YARMOUTH
BUILDING DEPARTMENT
PLEASE PRINT:
Job Location:
CONSTRUCTION SUPERVISOR FORM
S' �', OLC
tvumoetrect U l /1/I D �Cjj b wil )" Village
Owner of Property:
Construction Supervisor: \ L4� IV' lJullV,-, //-yob' S'OS-790- y9y7
�p RRR Ntrme �� (� Lic
6� ense No. Phone No.
Address: Uro'� G/f; "' f� 44, ajao
Licensed Designee:
(If other than Supervisor) Name License No.
2.15 Responsibility of each license holder:
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfully violate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board. •
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes 4 No
If you have checked yo, please indi ate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity ❑ Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
of Ovyffe} or Owners
Owner ❑ Agent
Signature:
Building Official Approval:
r,.
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 lNashington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Address: bt F.d� !L
City/State/Zip: SI {>Ithl S ✓lf44 ONO Phone #: _So
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with i- 4. ❑ I am a general contractor and I
employees (full and/or part-time).' have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
employees and have workers'
comp. insurance.t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I LEI Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*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 anew affidavit indicating such.
:Contractors ttut check this box roust attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors 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: I rpoyr! �i IUSSI s
Policy # or Self -ins. Lic. #: J B gd O 1 Expiration Date: l b D
Job Site Address: In 1 �sUtili Rr/ 'J >� 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
I do
use
City or Town:
of perjury that the information providecd/ above is true and correct.
Date:
f'h _
not write In this area, to be completed by city or town of vial
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employees to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self -insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, NfA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 11-22-06 www.mass.gov/dia
TOWN OF YARMOUTH BUJU
UAM
114tiROUTEn souniYA1e ouni W*AC-HUSrM028614l31 GAS
Telephone (b08) 3§8.2231, fit. 291 — Fa: (b08) 398.2388 PLUM
BUILbING DEPAIRTW=NT SICN3
DAMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 34 and 780 cMX Chapter 1, Sectioa 111.5,
I hereby certify that the debris resultinsr from the ro sed k
conducted
waek
N p po wor /demolition to be
Is to be disposed of at the following locadon:
Said disposal site shall be a llcensed solid waste facility as defined by M.G.L.
Chapter 111,•Section 130A.
�pucang
Permit No.
Fr
e
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 eit. 261 Fai SOW98-0836
BUILDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE
Address of Proposed
Sal, 9W&
r
Scope of Proposed Work: 1 -alAh i r t-b
Date:
Based on the scope of work described above, the applicant is required to obtain approvaWsign-
offs from the following departments as checked -off below:
Health Dept. — Town Hall Phone No. 508-398-2231 ext. 241
Conservation Comm.— Town Hall Phone No. 508-398-2231 ext. 288
Water Dept.— 99 Buck Island Rd. phone no. 508-771-7921
Old Kings Hwy. Hist Comm.— Town Hall phone no. 508-398-2231 ext. 292
Engineering Dept. —Town Hall phone no. 508-398-2231 ext. 250
6'i e-r
' 5 Flre Dept---GapLeileher, 96 Main St. So. Yarm, phone no. 508-398-2212
Other
Appropriate plans and/or application shall be provided to each of the departments checked -off
above. Each of these regulatory authorities has their own requirements outside the jurisdiction of
the Building Department. All applicable approvals shall be obtained prior to submitting a
building permit application to the Building Dept.
Thank you for cooperation.
BoaTid of eenalh�ttf(Gidf�.�G��r��� rdl�
Construction Supervisor License
License: CS 71488
nryl Birthdate: 5/24/1962
Expiration: 5/24/2009 Trf 16820
Restriction: 00
JOSEPH A BUTLER
PO BOX 616
SO DENNIS, MA 02660 Commissioner
o L• Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Reglatration: 128086
Expiration:
2/27J2009 Tr1t 127876
Typo: Individual
JOSEPH A. BUTLER
JOSEPH BUTLER
91 SOUTH STREET
SOUTH YARMOUTH, MA 02604 Administrator
ACORO. CERTIFICATE OF INSURANCE
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ALTER THE COVERAGE AFFOFDED BY THE POLICIES BELOW.
Worcester 126 01613
Phone: 508-755-5944 Tax:508-191-9841
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453 Chandle St.
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453 CHAITOLLR ST.
WORCESTER IM 0160:
12CO11321 •''
TOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site
Proposed Improvement:
►r Map No:. /
'I�S 5, bw�i�+P.+vLv
�We-Z nr,. v 9m. ) 7r.
Lot No.
Applicant: 0Tel. No.: S01-�F0�3 oZS�
l/FCIJ� r. Pn 3& 6l
Address: ,22? ,)I � (� � S, Lelln j &- 0 (0 Date Filed:
**Ifyou would like email notification of sign off, please provide e-mail address:
Owner Name: �J 1 /lAb D) G bwnn )
Owner Address: #Y `t' l /e^l P,01 Wb 1:4, A4 Owner Tel. No.: <6- 7fF- 377P
RESIDENTIAL AHD/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit four (4) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY:
PLEASE NOTE
COMMENTS/CONDITIONS:
YARMOUTH FIRE & RESCUE
Commercial Building Permit Sign Off
Project Name Surf n Sand
Contact Name Joe Butler
Address 277 S Shore Dr.
Phone # 508-7604949
Y NO NA Subject Regulation
E
S
X
Access for Fire Apparatus
527 CMR 25.02
X
Building Numbers
MGL Chapter 148 see 59
X
*Flammable gaslliquid storage
527 CMR 14.03
X
Fire Lanes
527 CMR 10.03(10)
X
*Service Stations
527 CMR 5 & 9
X
*hazardous Materials Storage
527 CMR 25.08
X
*Kitchen Exhaust Systems
780 CMR, 527 CMR 10.03(8)
X
Extinguishers
527 CMR 10.02, Chapter 148 sec 28
X
*Fire Alarm Systems/CO detection
780 CMR, Chapter 148,527 CMR 24,CMR 31
X
*LPG Storage
Chapter 148 sec 9,10,28 & 527 CMR 6
X
Pesticide Storage
527 CMR 37
X
*Sprinkler Systems
780 CMR & Chapter 148 sec 26 A -I
X
Storage inside/outside Buildings
527 CMR 10.03(5)
X
*Upholstery
527 CMR29
X
*Trash Containers
527 CMR 10.04 & 34
X
Any Hazard to the Public
Chapter 148 sec 28
X
*Curtains Draperies, Blinds
527 CMR 21
Description of planned project/other requirements:
* YFD permit required- pendi=on upancy and submittal
Plan Reviewed By: Date:1laa/d cr
-- --- ------------------------------ - ---------------------
Copy for Applicant opy to Building Department2E�5- Copy to Fire Prevention-
FILF� COPY
lI
�I r
v o.
5
G
r
12
1?
14
15
16
17
18
19
20
21
22
23
24
25
26
27
2U
29
,0
II
R1677?le- 4,4 RPPlatt
N.ew flilrY y � e be
fk5b '
wlila
a r TOWN OF YARMOUTH Building Department
(508) 398-2231 ext.261
BUILDING `
PERMIT NO - B-08-1026_
w ISSUE DATE 3/11/2008 _ ; PROPOSED SE
PERMIT
APPLICANT JOhnDeCourcey - JOB WEATHER CARD
..........................
PERMIT TO Repair
AT (LOCATION) 10277SOUTH SHORE DR ZONING DISTRIC R-25 Bldg. Type: Commercial
SUBDIVISION MAP LOT BLOCK 1026.127 BUILDING IS TO BE: CONST TYPE= USE GROUP
LOT SIZE
CONTRACTOR
strip and reroof, 10 squares, paper and vent to code
REMARKS : I
AREA (SO FT) EST COST ($ $9,375.00 PERMIT FEE ($) $120.00
OWNER DIGIOVANNI, SILVIO V -- -- -- BUILDING DEPT BY
ADDRESS 10277 SOUTH SHORE DR
South Yarmouth I MA 102664 1 PHONE
INSPECTION RECORD
LICENSE
IDeCourcey, John
P.O> box 80265
Stoneham MA 02180
7812790885
FIELD COPY
Date , I _Note Progress - Corrections and Remarks I Inspector
Ilse Only
At
IFee s /10,yU(/
1 Permit expires 6 months from
issue date.
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
/7 . (508) 398-2231 Ext. 261
CONSTRUCTION ADDRESS: a / % 6a— --�f1 S/L u
ASSESSOR'S INFORMATION:
Map: Parcel: ml
12
OWNER
NAME PRESENTADDRESS
W �A- 0—"eo
CONTRACTOR /�a� �/ r " 7'"'7� Fl��-G 7£s�—z 79-
NAME AILING ADDRESS TEL#
` 93 75,O)
❑ Residential C�Commeseial Est Cost of Construction $
Iiome Improvement Contractor Lic. # Construction Supervisor Lie. #
Wotkman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp. Policy#
WORK TO BE PERFORMED
a Tent (Fire Retardant Certificate attached)
Duration Wood Stove
❑ Siding: p of Squares ❑ Replacement ow'�? q
/ D Rcplacomeutdoom- # D I� 11a 1,1U`
dRa r�F ers e. to MAR 1 08
Stripping old shingles* ()going over layers of existing roof ,
*The debris will be pose at: G D
A
n of Facility y
I declare under penalties of perjury a ementsa
ue and e t to the best of my knowledge and belief: I understand that any false answer(s)
will be just cause for denial or revoca ' a of my license and far prosecution under M }.L 269, Section 1.
lirant's Signature:
Owners Signature (or anachm
Date
Approved By: Date:
Building Official (or designee)
Zoning Distric
Historical District: ❑ Yes No
Water Resource Proteplion District:
❑ Yes
r 12c;1
Flood Plain Zone: Yes
Within 001 of We \\tlands:
Yes ❑ No
❑ No
3/01
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
`V www.mass gov/dla
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name
Address: , t, 6 or
City/State/Zip: 021cfo Phone M 7el - 279- 0&ff6_
Are you an employer? Check the appropriate box:
1. ❑ d am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees
- working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. (No workers' comp.
insurance required.] t
These sub -contractors have
- - employees and have workers'
comp. insurance.t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
C. 152, § 1(4), and we have no
employees. [No workers'
comp, insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
10.❑ Electrical repairs or additions
11. Plumbing repairs or additions
12.Qfftof repairs
ME] Other
-Any appttcant mat checks has SI nust also tip out the section below showing their workers' compensation policy information.
t Homeowners who subrrut this affidavit indicating they are doing all work and then hire outside contractors trsut submit a new atrrdavit indicating such.
tContractors that check this box neat attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
cnVloyces. If the subcontractors have employees, they must provide their workers' corm. 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
Policy # or Self -ins. Lic. M ef /D2. 3 <—a Z 7 e 1 Expiration Date: I 1 Z.i'O
Job Site Address f $xK11 � 0 277 S `—t�/L� p� City/StaWZip: gA6e: j Y-e, 414— OuE,te
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 S 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
I do he by ce ti der the ppb ns an enahles of perjury that the information provided above is true and correct
Si era r a 3 O� _
Phone k:
7.
use only. Do not write in this area, to be completed y c or town q
,(/ielalelal
City or Town: Permit/License #
Issuing .Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person' Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representative of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of it license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for. the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cant' workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self -insured companies should enter their
self-insurance license number on the appropriate line
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. !# 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 11-22-06 "Nv.mass.gov/dia
Fax Server
r
1t
3/11/2008 1:40:26 PM PAGE 2/003 Fax Server
ACORD CERTIFICATE OF LIABILITY INSURANCE
TPA
OAT03112 OB »
PRODUCER Pnmc (74')977.1100 =n 1791)In9043
SALEM FIVE
BOYLE INSURANCE SERVICES, LLC
THE CERTIFICATE C ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THM CERTIFICATE DOES NOT AMEND, EXTEND OR
445 MAIN ST BOX 605
ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
WOBURN MA 01801
INSURERS AFFORDING COVERAGE
NAIL i
0I0URE0
INSURERA ArrisncanCasCcOfReadingPa
20427
JOHN DECOURCEY ROOFING CO INC
INSURER 6 Transporta0on Ins Co
20494C
P O BOX 60266
STONEHAM MA 02180
INSURER C: Transportalan Ins Co
20404C
INSURER D:
INSURER E
COVERAGES
THE PCLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AEOIE FOR -NE -OUCV PERIOD INDICATE:, NOTWTHSTNNDINO
ANV R-AOLIRiMEN-, -ERU CR CONDITION OF ANY CONTRAC- OR OTHER DOCUMEN- W H RESPEDT TO JhICH TH'S CERTIFICATE MAY Bi ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POJOE3 DESCRIBED HEREIN 13 SU&ECT TO ALLTHE TERM3, EACL.31ON3 ANC CONDTION3 OF SUCH
PCLICIES. AGGREGATE -WITS SH3 M MAY HA'A BEEN REDUCED BY PAID CLAMS.
OR
"""ITYPEOPIN9URJWcs
POLICYR M6ER
POUDYEMeTNM
P%cYFanRAmj6
UNITS
GENERALUABBJTY
C1023532426
04112107
04112/08
EACH CCCURRENCE t 1,000,000
DMIAOCTOFLNT31 1 100,000
X =AMERCIAL GENERAL LIAOLTY
CLAIMCMADEu CCCUR
_._ _
__..
MID EXP(A-Vwepx ) 1 - - - 5,00
PERSONAL &ADV'NJURY 1 10000DO
A
GENERA.AGGREGATE 1 2,000,000
GENL AGGREGATE-4T A►RIES PER.
►RODUCTS.CCNP!CP AEG. f 2,OOD,0DO
PRD-
►0.IGYJECT LOC
AUTOM013LLE
LABILITY
ANY AUTO
1077798827
04112107
04112/08
COMBINED SINGLELIMIT
(EA A001dert) 1 11000,000
BCDL• INJURY
ALL OWNED AUTOS
SCHEDULED AUTOS
(Pr prt�n)
1
X
B
-IPECAUTOS
\ON-OVAJED AUTOS
X
BCOL` INJURY 1
(Per Pladel:
X
PROPERTY DAIAGi II
Me, saint-t'
GARAGE LIABILITY
AUTO CNLY•EAACCIDENT t
OTHER THAN EA ACC t
ANY AUTO
AUTO ONLY: AGG 1
EXCE33 I UMBRELLA UABEITY
EACH CCCURRSNCE f
OCCUR CLAMS VAOE
AGGRECATE 1
f
CEDUCTIBLE
1
RETENTION t
{
C
WORKERS COMPENSATION AND
EMPLOYERS' LJADIUTY
oncmwM,rulicLlclDT
WC182109656
04/12/07
0412108
TOFY-NITS arH�
EL. EACH t 100,000
EL. DISEAE-EAEMPLOYEE f 100,000
P Y� rrnb ,P�An
s 11LIAL ►ICYBIpCIrBr
EL. DI ;EAFraIr Ln+r s 600,000
OTHER:
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT) SPECULL PROVISIONS
Job; Sea and Sands Hotel
CERTIFICATE HOLDER CANCELLATION
S-CULD ANY OF THE ABOVE DESCRWEO ►O-'OES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF THE ISSU'N3 INSURER WILL ENDEAVOR TO MAIL-0 GAYS
WRr-TEN NOTICE TO THE CERTIMCAT'- HOLDER NAVED TO THE LE'T, BU-FALLR?
TOWN OF YARM OUTH
-O 00 50 SHILL IMPOSE NC OBLIGATION OR UAE -ITY OF ANY PJND LPON THE INSURER,
114B ROUTE 28
ITS AGENTS OR REPiESEN1TATY3.
SOUTH YARMOUTH MA 02564
Attention: JAMES BRANOOUNI
AUTHOAZED REPRESENTATME
Gerard F 6 Jr
ACORD 25 t2001108)
Comcatc A 13917
O ACORD CORPORATION 1988
Fax Server
3/11/200B 1:40:26 PM PAGE 3/003 Fax Server
IMPORTANT
If the certificate holder Is an ADDITIONAL INSURED, the pdicy(les) must be endorsed A statement
on this certificate does not confer rights to the cortificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain pdicies may
require an endorsement A statement on this certlicate does not confer r1g1tts to the certificate
holder In lieu of such endomnment(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the Issuing Insurer(s), authorized representative or producer, and the certificate holder, nor does It
affirmatively or negatively amend extend or alter the coverage afforded by the poldes listed thereon.
ACORD 25S (2001108) Certificate #13917
J JOHN COURCEY ROOFING CO. INC
Commercial Roofing
JOHN DECOURCEY
Owner and President
r-ti.1n Su w
�(rN,til i5 10a 44' Alter
/`��£ L7�►%cpiko /��- � �•*.�s✓ •moo u/�
/ �o�yi�o - �' /pa, u2,a�% �Lc:r��/�o-�ca•c, .1-,�..s�/a�,?.a1 ��-cou-C_
b � �1�.✓; r�Gi-ras+�,A � cog �->e� s�- �,-,-�
Odic ,�v O 144JU> sV4.&=W4� .'v54ze, Okp E IA-v ee�
LJo¢lG 5P� 6es, 10 ge41u
49 3 ,
P.O. Box 8023T- St fneham, MA 02180
Tel:781-279-0885 ax:781-231-0536
Fully Insured and Licensed
G
APPLICATION FOR PERMIT TO DO GASFITTING
(OFFICE USE ONLY)
By
Fee: $ 3Scb
JUL 0 2006
PERMIT NO.C�.'—O7 lXaa
Date i 4 06
Buildin 7 Owner's
AT: Location o? 7 50CEf L Name S�'v)2s
S. Ilk? cSy?F y-Si}w✓6
Newly' Renovation ! r Replacement ❑
Plans Submitted Yes ❑ No Dt"
Type of Occupancy 1h&414:e—
UJI
(PRINT OR TYPE)
Installing Company Name
Address Yye7
Check One:
R . .
❑ Partnership
❑ Firm/Company
Business Telephone `39'' 9JO7
Name of Licensed Plumber or Gasfitter
INSURANCE COVERAGE:
Check One
have a current liability insurance policy or its substantial equivalent. Yes I$ No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy �a' Other type of indemnity O Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of
the Mass. General Laws,
and that my signature on this permit application waives this requirement.
Check One:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted
(or entered) In above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed
under Permit Issued for this application will be In compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
✓16
Signature of Licensed
Plumber or Gasfitter
/ W— o7p-g
License Number
TYPE LICENSE:
❑ Plumber 0 Gasfitter 2Master ❑ Journeyman
TOWN OF YARMOUTH
BUILDING
ELEURICAL
BUILDING DEPARTMENT
el.vMsw.
GAS
1146 Route 28, South Yarmouth, MA 02664
ZONING
508-398-2231 ext. 261 Fax 508-398-0836
SIGN CODE
Inspection and License Report
Address 2 7� `" �` — '�— / Business Name
Date of Inspection 0 7 Contact n // oIle y Phone I Ty'r % � •
During the annual inspection of your premises, performed in accordance with the provisions of Section 106 of 780 CNIR (Massachusetts State Building '
'*.,.Code), the Board of Selectmen and/or the Board of Health rules, the following violation (s) were observed:
dress -
❑ Emergency egress signage Location
❑ Emergency egress lighting Location
❑ Egress door hardware location
❑❑ Maintenance of exits
location
LAY Guardslliandrails
Location
Icchanical
❑ Combustion Air
Location
❑ Vents
Location
❑ Storage in boiler rooms
Location
❑ - Automatic door closures
Location
on boiler room doors
Smoke Detectors Location
J / c
Other Location / �i.�, ,., ..4 1 /' ll �.i �.ii.�i i v J/nJ/
Deck/Stairway Certification
7 ' 2 Jam_
780 C11IR Section 103 MAINTENANCE provides that the owner, as defined In 780 CNIR Chapter 2, shall be responsible for proper maintenance.
In order to abate the above violaL'on(sl you mu<t:
❑ Make corrections immediately and contact thisofficefor a follow-up inspection.
al', k corrections within /v �' _. days and contact this yfhce for a follow-up inspection.
Local Official / Inspector//' "',/ • �� �n/'' ``� ` `'/�
Received By: �l'i t � L i �� �/ Title c ,-
oe
Rev. 3104 Original -Premises / Yellow -Building Department Pink -Licensing Authority
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the blassachuseus Electrical Code, (bIEC), 527 ChIR 12.00
3�+ OF 1•q9; (OFFICE USE ONLY)
SOWNOF Y OJ TF By
,7 ']� Fee: $ .!TO-DO
n in 1 r 2007
� O PERMIT NO. E —1135
(PLEASE PRINT 1 — r0 MATION) Date:
4 To the Inspector of tres: By this application the undersigned gives notice of his or her intention to perform the electrical
work described below. c y�
Location (Street & Number)CQ9 Ja✓t1n ���fQ
Owner or enan / T I phone No. �%u�Ya
�Owner'sAddress n (0
'KIs this permit in conjunction] with build', g permit? ❑ Yes • o (Check Appropriate Box)
`a Purpose of BuildingVIS G 001NrL Utility Authorization No.
\Existing Service Amps / Volts OverheadO Undgrd Q No. of Meters
New Service Amps / Volts Overhead❑ Undgrd Q No. of Meters
Number of Feeders and Ampacity
`Location and Nature of Proposed electrical Workw (�(i� Ylnm (Q26cip a4zx'k�,
Ilo I e
Cnm letinn of the following table may be waivedby the Ins error o Wires
No. of Recessed K#A
No. of Ceil.-Susp(Paddle) Fans >_ afjc
No. of Tota
Transformers NOIA KVA _
No, of Liphting Outlets
No. of Hot Tubs 00 tie
Generators Akl KVA
No. of Li htip Fixtures
Above n-
SwimmingPool md. md. ❑
o. o Emergency Lighting
Batev Units CJ lhr
No. of Receptacle Outlets
No. of Oil Bumers IJ
FIRE ALARMS
No. of Zones
No. of Switches 22
No. of Gas Burners yhk
o. of Detection an C
InMating Devices I✓Ott/
No. of Ranges
g ^/p [.►£.
Total
No. of Air Cond. � %} Tons
No. of Alerting Devices tin
No. of Waste Disposers /✓OI`/E
Heat mp
Totals:
um cr
—
ons
— —
— —
No. of Self -Contained
Detection/Alertin Devices N�/¢
No of Dishwashers ,(/o til E
' //
Space/Area Heating KW NONE
MCounic[pal ❑ Other
Local � nnection
No. of Dryers NOUC
Heating Appliances KW pne
/V
Security Systems: i ,
No. of Devices or ui valent G iU
No. of Water
Heaters - KW
No. of No. of
Si ns �aNE Ballasts
Data Wiring:
No. of Devices or Equivalent 0I1C
No. Hydromassage Bathtubs I✓Ot/ E
No. of Motors Total. HP
Telecommunications Wiring: l��
No. of Devices or uivalent A
Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no pemht for the performance of electrical work may be issued unless the licensee provides
proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in
Ns�force, and has exhibited proof of same to the permit issuing office.
t tlijECK ONE: INSURANCE BOND[3 OTHER (Specify:)
tki (Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
(�l I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
�� FIRM NAME- LIC. NO.
f.,�l.icensee: A F. Signature— � LIC. NO.�/ Z r—
u,a r � ..,� . t4ta � �,
rJ (lf applicab e, ter "exempt in $e license umber line.)/ � us. Tel. No.:
Address• I '�C , Of C - Knlr=lM Alt. Tel. No,.;fdSr -,3tZ, =�5 55
V OWNER'`�AIV am aware that'thc Licensee does not have the liability insurance coverage normally required by law. By my signature
below, I hereby waive this requirement. I am the (check one) owner owner's agent. ❑
Owner/Agent
Signature Telephone No.
[Rev.04/00]
.." OF r+R'�g TOWN OF YARMOUTH
BUILDING DEPARTMENT
e1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 261 Fax 508-398-0836
Inspection and License Report
Address 2 7 p \ Business Name J 1 "
Date of Inspection 711 y' t� �' Contact Phone
BUILDING
ELECTRICAL
PLUMBING
GAS
TONING
SIGN CODE
During the annual Inspection of your premises, performed in accordance with the provisions of Section 106 of 780 CDIR (Massachusetts Stale Building
Code), the Board of Selectmen and/or the Board of Health rules, the following violation (s) were observed:
❑ Emergency egress signage Location
❑ Emergency egress lighting location
❑
Egress door hardware
Location
❑
Maintenance of exits
Location
tr Guards/Handrails
Location
Mechanical
❑
Combustion Air
Location
❑
Vents
Location
❑
Storage in boiler rooms
Location
❑
Automatic door closures
Location
on boiler room doors
Smoke Detectors Location
Other Location
Deck/Stairway Certtftcation
780 CDIR Section 103 MAINTENANCE
i
j IJ 0or, / f k �/,/ !i•F l / t�,'r c -f/ 07—
'
dill 1 / .n Lvt c�c
Z' /ill rt Acd vs ✓i oo
Aof ' / S c d Nf
i�9 lInc iVe KC is '/ t: _f0(/
) % .—..4
(/u /r(tI.
.t r�
IV //
cliwnc/ . J�A' HcG—a j/c
ides that the owner, as defined in 780 CDIR Chapter 2, shall be responsible for proper maintenance.
IIn order to abate the above violation(s) you must:
1� Make corrections immediately and contact this office for a follow-up inspection.
❑ Make corrections within yy qnd contact th' voiice fo o w-up inspection.
Local Official / I for
J /i r/Gw ` • //7 t
Received By:C�t� Tide l� t��r
Rev. 3/04 Original -Premises Yellow -Building Department Pink -Licensing Authority
TOWN OF YARMOUTH BUILDING
IIECIRIG,L
BUILDING DEPARTMENT PLUMBING
GAS
1146 Route 28, South Yarmouth, MA 02664 ZONING
508-398-2231 ext. 261 Fax 508-398-0836 SIGN CODE
Inspection and License Report
Address 2
7 y U
rr 4 / • Bhsiness Name
14%
Date of Inspection
7•��' �'
\
Contact U ^� / o��(' Phone _i
' % u 3 70c)
During the annual inspection of your premises, performed in accordance with the provisions of Section 106 of 780 CNIR (Massachusetts State Building
Code), the Board of Selectmen and/or the Board of Health rules, the following violation (s) were observed:
Eeress N0//C� 0 T/�/i/
❑ Emergency egress q signage Location
❑ Emergency egress lighting Location
❑ Egress door hardware
❑ Maintenance of exits
e Guards/fiandraits
Mechanical
❑ Combustion Air
❑ vents
❑ Storage in boiler rooms
❑ Automatic door closures
on boiler room doors
Location
Location
Location
Location
Location
Location
Location
Location
Location
IW1A,OorJ1 AjJJi '`f e-
IIj
111
/r/ � v/1G /fie rC /C G✓��
0 C /y ,z - 6 dl-x,.4 //-yt I-
uo ''+ t' c /lvrnee-
i S C 41A,1 • / < fl, IV / /
780 CMR Section 103 MAINTENANCE provides that the owner, as defined In 780 CMR Chapter 2, shall be responsible for proper maintenance.
In order to abate the above violation(sl you mt: us
i� Make corrections immediately and contact this office for a follow-up inspection.
❑ Make corrections within d contact ' vie f o w-up inspection
Local official / I p fctor � //✓� 1 Z_ ' �� 4, /
Received By: 0 Title. -
Rev. 3/64 Original -Premises Yellow -Building Department fink -Licensing Authority
v
=Z'
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
covai 2 Ctow(p I(OFFICE USE ONLY)
TOWN OF YARMOUTH
`M
"(PLEASE PRINT IN INK
ZIS To the Inspector of Wires:
work described below.
Location (Street & Numbi
4 Owner or Tenant S, W i
P Owner's
By
Fee: $ by
PERMIT
OR TYPE ALL INFORMATION)
By this application the undersigned gives notice of
0
7
nI 1l I - 1_I II \"I
0tenjign id perform the electrical
r _,e J
Is this permit in conjunction with a building permit? LM Yes QNo (Check Appropriate Box)
�&urpose
of Building & V N Crl5 I /-'W Swtknmt%i- IOGL Utility Authorization No. 11,4
Existing Service Amps 1 ZO / '2-qo Volts Overhead❑ Undgrd Q' No. of Meters
w Service 3 O Amps 1'7-1 /-z10 Volts Overhead❑ Undgrd [9'' No. of Meters 6
V
M Number of Feeders and Ampacity T/34cto - 30 q�os
,,*Location and Nature of Proposed electrical Work: A2oo,Io POOL. POOt- Lt6-H71kP_,, 6-iYS %feiyr riz �r,dTnoc S
4
-it0�.- P11)roIL-q/.%t.+P e+.CS,
I Nil Z'kCom letion o the ofowin table may be xaived b the Inspector oWirescesscd
7
Fixtures �-
Ceil.-Susp.(Paddle) Fans —
No. o Tota
Transformers KVA
No. of Li htin Outlets
No. of Hot Tubs —
Generators — KVA
No. of Lighting Fixtures
Above n-
Swimming Pool md. ❑ md.
No. o Emergency Lighting
Battery Units ~
No. of Receptacle Outlets .1
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners I
o. ot Detection an
Initiating Devices —'
No. of Ranges
Total .�
No. of Air Cond. Tons
No. of AlertingDevices
No. of Waste Dis osers -
p
eat mp
To s:
um er
ons
— —
_ _
No. of Self -Contained _
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW —
P g
Local Q Municipal
Connection Other
No. of Dryers --
4'
Heating Appliances KW _
g PP
Security Systems:
No. of Devices or Equipvalent �-
No. of Water
Heaters 1 KW GA S
No. of No. of
Signs — Ballasts
Data Wirin :
No. of Devices or Equivalent
No. Hydromassage Bathtubs �-'
No. of Motors I Total HP 'tZ
Telecommunications Wiring: _
No. of Devices or uivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may be issued unless the licensee provides
proof of liability insurance including "completed operation' coverage or its substantial equivalent. The undersigned certifies that such coverage is in
force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE s BOND OTHEREr(Specify:) OWideiL Id1,N11e0 -- S-ee Se44 c.>
Estimated Value of Electrical Work: �, 00 policy.)
anon Date)
.S� (When required by municipal policy.)
Work to Start: ZZ UZ>4-3 -0a (r Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME E X. 41) 7,20LH LIC. NO.? +6 10 L
Licensee: Gf= RARp ,T, �YJ/}Z-LOLN Signatur '�r LIC. NO. . -4(o 10 E
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No,5"0$-••-79,V- S-6 99
Address- 8 24U7E a-8 rryHa/HDortf, AM- 0,31-664 Alt. Tel. No.:,SOQ-32ff -SG7R
OWNER'S INSURANCE WAIVE : I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature
below, I hereby waiv this requirement. I am the (check one) owner owner's agent.
�>(
Owner/A en $(J� ��-�5550
Signature v"` Telephone No.
[Rev. 04/001
List of Professionals
.ti
Page 1 o_ 1
Homo i Map i Tootbox l t 1p r. --
t� Cantnusnr'tulth u ;!Y1tiI t1 a«.
.Unsadmsrus
Damian of
!'mf.•ssiunalJ.l..•n�wv �
Licenses fitting search criteria:
Profession equals Electrician
License Number equals 24610
Licensina License License
Board Im Number
Electricians Journeyman 24610
Electrician
T Class E
Name C' State License
Status
MAZZOLA GERARD J. SOUTH Current
YARMOUTH, MA
Your search has resulted in 1 licenses
Division of Professional Licensure
239 Causeway Street
Boston, Massachusetts 02114
Phone: (617)727-3074
Please send your technical questions or
comments about this web site to
RE G. W ebMastcr(a, St atc.m a.us
Disclaimer
Privacy Policy
Enforcement Process Glossary
http://licease.reg.state.ma.uslpubliclpubLicRange.asp?profession=Electrician&UcenseNo=... 3/20/2006
TOWN OF YARMOUTH BUILDING
>:I.Eclx,cAl
BUILDING DEPARTMENT Mt""°`NG
GAS
1146 Route 28, South Yarmouth, MA 02664 ZONING
508-398-2231 ext. 261 Fax 508-398-0836 SIGN CODE
Inspection and License Report
�/ ,
Adores � �% / �.,✓' I-^'v /. Business Name r , .� r z '0. k
Date of Inspection i 'Z f�' /' /' Contact Phone ` e H
During the annual inspection of your premises, performed in accordance with the provisions of Section 106 of 780 CNIR (Massachusetts State Building J
Code), the Board of Selectmen and/or the Board of Health rules, the following violation (s) were observed: 1
dress
❑ Emergency egress signage Location
(
❑ Emergency egress lighting Location
❑ Egress door hardware
Location
❑ Maintenance of exits
Location
�"� `" r`^ �� �`
��r�
T �� l~ /' t•l
Guards/Handrails
Location
1
Mechanical
❑ Combustion Air
Location
❑ Vents
Location
❑ Storage in boiler rooms
Location
❑ Automatic door closures
Location
on boiler room doors
Smoke Detectors
Location
/t r/. • r/� t l
"
%' "' 41
Other
Location
t I /: .� /i� ,� -
C i t r� .Li. �• / -� Z r ��
Al de,
r
Deck/Stairway Certification
780 C111R Section 103 MAINTENANCE provides that the owner, as defined in 780 OUR Chapter 2, shall be responsible for proper maintenance.
In order to abate the above violation(s) you must:
1
❑ Make corrections immediately and contact this office for a follow-up inspection.
Makc corrections within / /C` �� /i 1. w - da%s'and contact this office for a follow-up inspection.
Local OfrwW / Inspector
Received By: Title
/t •'A �
Rev. 3/04 Original -premises Yellow -Building Department Pink -Licensing Authority
c5e d qeSe4.+�e ui-�jxd 446,,
TOWN OF YARMOUTH Building Department
BUILDING
(b08) 398-2231 ext.261
PERMIT NO _ 8-06-744 :
PERMIT
ISSUE DATE ; • 11/25/2005. ; PROPOSED USE '
APPLICANT hSabao -------------'
.........
JOB WEATHER CARD
PERMIT TO 'Misc.luiground pool;
AT (LOCATION) 100277SOUTH SHORE DR ZONING DISTRIC R-25
SUBDIVISION MAP LOT BLOCK 1026.127 BUIL rIO E: CONST 1
LOT SIZE
Install inground pool as per plans
REMARKS
Bldg. Type: Commercial
'E= USE GROUPC
AREA (SO Fr) EST COST ($ $50,000.00 PERMIT FEE ($) $75.00
OWNER ISILVIO V DIGIOVANNI BUILDING DEPT BY
ADDRESS 00277 SOUTH SHORE DR
South Yarmouth MA To2664
PHONE 15083989556
INSPECTION RECORD
CONTRACTOR
LICENSE 027999
Andrews, Rooney
1647 Lowell Road
Concord MA 01742
8002727946
FIELD COPY
Date
Note Progress - Corrections and Remarks
Inspec or
P lJ� Awl
1�t od 6 z.�.
�� — K •"� �>,�/ lv!!'t� A be 7-10.0C
TOWN OF YARMOUTH BIB
BUILDING DEPARTMENT PLUMBING
GAS
1146 Route 28, South Yarmouth, MA 02664 ZONING
508-398-2231 ext. 261 Fax 508-398-0836 SIGN CODE
Inspection and License Report
Address 1217 fl l l , — t: & • Business Name �✓ / �` /�—�( / /T�/
\ i
Date of Inspection �'�/�' �' Contact U •"/ r °��c i Phone ) 0 ! u %vU
During the annual inspection of your premises, performed in accordance with the provisions of Section 106 of 780 CAIR (Massachusetts State Building
Code), the Board of Selectmen and/or the Board of Health rules, the following violation (s) were observed:
Eivress /Uo71C 0 L 61 6 %/,l /lam
❑ Emergency egress signage Location
❑ Emergency egress lighting Location
❑ Egress door hardware Location
❑ Maintenance of exits Location
Guards/fiandrails Location /Vw r c+� i /h o rr / A 1 0-f / /4.
�77
Mechanical
❑
Combustion Air
Location
❑
Vents
Location
❑
Storage in boiler rooms
Location
❑
Automatic door closures
Location
on boiler room doors
Smoke
Detectors
Location
i
Other Location !
t
Deck/Staimily Certification —/
780 CAIR Section 103 MAINTENANCE
b1 f
l f / n1 rt r/� ut ✓2
!/ I•�nC /VC /C /C k/��
/ I .t /
L (:yt CiC.
� . U6 �J�r� �L� �s it r�/c i�tc,� i%.'^- �c (r'1•%�/c i.�i/lam/��
that the owner, as defined In 780 CMR Chapter 2, shall be responsible for proper maintenance.
In orL der to abate the above vioLon(sl you must:
CY Make corrections immediately and contact this office for a follow-up
n inspection.
❑ Make corrections within yud s contact th
jow-up inspection.
,,) L
Local Official / Inspector I X
i
Received By: \�%Zl/ 1 %i r i Title
Rev. 3/04 Original -Premises Yellow -Building Department Pink -Licensing Authority
BUILDING PERMIT APPLICATION
APPLICATION TO CONSTRUCT. REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF,
OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
Town of Yarmouth Building Department • 30�
1146 Route 28 • -Yarmouth, MA 02664-4492
Tel: (508) 398-2231 x261 • Fax: (508) 398-0836�/
Office Use Only P ning Board Information
Permit No.% Date a Type
Assessors Department Information:
Map rot
Permit Fee $
Endorsement Date
/ t27
Reding Date
New
Deposit Rec'd. $ Date
Net DUB
No
or
1.4 Property Dimensions:: e
Lot Area (sf) Frontage (it) Lot Coverage
This Section for Office Use Only
Building Pe
ber.
Date Issued:
Ma
6 =D
IJ-1
Certificate of Occupancy ,
Signature:
. Bulking Official
Date
.. Is is not required
Section 1 - Site Information
1.1 Property Address:
277 Scxx .tSiEoci:.E
i�E
1.2 Zonin Information:
Zoning District
5f'MI•CDMMKt:
e
Proposed Ube
__Soua�/3C�+ov.C1>, BMW
1
,
1.3 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
30 t
2so
15
?ol
20'
\\0 +'
I Water Supply (M.O.L c. 40. S 541
Public Private
1.5 Hood Zone Information: Continents:
Zone: G BFE:
OVER
3.2 Registered Home Improvement Contractor.
,
Com any Name
Not Applicable ❑ r
Registration Number
•. •+6
Address M ( L.LM U'O' � O\�b2
(� �IJ�t L '' 1 1 `
Expiration Date
SlgnaturgG Telephone
Section 4 - Workers! Compensation insurance Affidavit (M.G.L 0.152 S 25C (6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result In the de ial of the issuance of the building permit.
Signed Affidavit Attached Yes..-4 .... No ..........
Section 5 - Professional Design and Construction Services • for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 1116 (containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect:
Not Appncable ❑
Name (Registrant)i
Registration Number
Address
Signature Telephone
Expiration Date
Section 5.2 Registered Professional En inee s
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Name • - ', i
Area of Responsiblltty
Address
Signature Telephone
Registration Number
Expiration Date
Name.
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
Section 5.3 General Contractor
Not Applicable ❑
Company Name
Person Responsible for Construction
Address
Signature Telephone
0r
2of4
0
Section 6 - Description of Proposed Work (check all applicable)
New Construction Q
(for multiple family only) No. of Bedrooms
(tor multiple family only) No. of Bathrooms
Existing Bldg. ❑ Repalr(s) ❑
Alterations ❑
Addition ❑
Accessory Bldg. ;a Type 0 L.—
Demolition
Other Specify:
Brief Description of Proposed Work: ,
. %IQ Cir- n
Section 7 - Use Group and Construction Type
Building Use Group (Check as applicapable)
Construction Type
A ASSEMBLY
❑ A-1 ❑ A-2 ❑ A-3 ❑
A-4 ❑ A-5 ❑
1A ❑
1B ❑
0 BUSINESS
❑
2A ❑
28 ❑
2C ❑
E EDUCATIONAL
❑
F FACTORY
❑ F-1 ❑ F-2 ❑
H HIGH HAZARD
❑
3A ❑
3B ❑
I INSTITUTIONAL
❑ I.1 ❑ 1.2 ❑ 1.3 ❑
M MERCHANTILE
❑ 14
❑
R RESIDENTIAL
❑ R-1 ❑ R-2 ❑ 1`1-3 ❑
SA ❑
50 ❑
S STORAGE
❑ S-1 ❑ S-2 ❑
U UTILITY
❑
1 SPECIFY.
SPECIFY:
SPECIFY:
M MIXED USE
❑
S SPECIALUSE
❑
Complete this section If existing building undergoing renovations, additions and/or change In use.
Existing Use Group:
Existing Hazard Index 780 CMR 34
Proposed Use Group:
Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area
Building Area Existing (if applicable) Proposed
Number of floors or stones
Include basement levels
Floor Area per Floor (so
Total Area All Floors (SO
Total Height (it)
Section 9 - STRUCTURAL PEER REVIEW 780CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes .......... No ..........
SECTION 10a OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNER'S AGENT OR QONTRACTOR APPLIES FOR BUILDING PERMIT
I, o , as Owner of the subject property,
hereby authorize ::RA!:p 14 A'Sc�T1 a O to act on
my a If, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
-- -- - --- ---- - -.-3 of 4----- �.--------- --- - .�. ---.OVER_--_ --
StG 1 IUN 1UD UV11NtFi/ AU 1 MUMILIZU Autry I ur%.t_AnAi IUty
�Mr-� b , as Own /Authorized A ent
hereby declare that the statements and information on the forgoing application are rue and acurate, to \
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Print
Date
S'6ction 11 ESTIMATED CONSTRUCTION COSTS
Rem Estimated Cost (Dollars) to be
completed by permit applicant
1, Building
°G�/firS0,OG`'
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
5. Fire Protection
S. Total a (I + 2 + 3 + 4 + 5) at50
7. Total Square Ft. ft r w. eruckm a addM") r
Check Below
❑ Conservation -Commission Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
4of4
V-P
PLEASE PRIM.
t vW1V Ur YAKMOUTH
BUILDING DEPARTMENT
CONSTR-U.CTIO.N•. SUPERVISOR FORM
Job Location: 4— r L
Number
Owner of Property:
Construction Supervisor.
Address:
Licensed Designee:
(If other than Supervisor)
-'Street
2.15 Responsibility of each licgtise holder.
Village
License No.
iLL
Phone
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfullyviolate subsections 2.15.1,2.15.2 or 2.15.3 or anyother section of these
rules and regulations and. any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor.who is to supervisethose persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be'reiporiaible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit condltroas.'
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection.as called for by the building official.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes '.�% No ❑
If you have checked ym, please indicate the type coverage by checking the appropriate box.
A liability insurance policy � Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
R , , X� L '_ ---I Check one: .
or
owner ❑ AWnt
Signature: Building Official Approval:
The Commonwealth ojtlfassaehusetts
Department of Industrial Accidents
smaadORWIJUM
600 Washington Street
Boston, Mass 02111
``any Workers' Compeasatlon Insurance ArNavit
Applicant Information:
City 40
Phone r
❑ 1 am a homeowner performing all work myself.
❑ 1 am a sole proprietor:.-d have no one working in an}••capacity
IR 1 am an employer pros !ding workers' compensation for my employees working on this job.
J1 . r► a _ ..
❑ 1 am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below who hav
the following workers' compensation polices:
Failure to secure coverage as required under Section 23A of A4GL 152 no lead to the Imposition of atog" pan of a an R so f 1.S0e.0a an"
mom
sue years' Imprisonment u wen as dvil penalties is the two of a STOP WORK ORDER and a mat of 311141 e a day agalast K I ndmatand tint a
COPY of this statement may he forwarded to the Office of Investigation night DU for eoverap verl/cadea.
t do hereby terrify
Print nami
and penalties of pedury chat the Wormadon prodded above It aye and cornet
official use only do not w rite In this area to be completed by city or Iowa etadal
city or town: !YARHODTIJ _ permlillicene M naulldiag Departmcat
cheek If Immediate response Is required hoard required 261 OSelectmeo's Oltice
p (508) 398-2231 ext. nOOthetb Department
eontaet person: hose M; _
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workercompensation fot their
entplo� ees. As quoted from the "law". an employee is defined as ever] person in the service of another under any;
contract of hire, express or implied, oral or written.
An empl(trer is def ned as an individual. partnership, association, corporation or other legal entity. or any two or more c
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer. or the
receiver or trustee of an individual . partnership, asso0. 1ciation or other legal entity, employing•employees. However the
owner of a dwelling house having not more than three,apartmenis %and wlto resides therein. or the occupant of the
d%%ell ine house of another who employs persons to do maintenance. construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an emplo%er.
NIGL chapter 1== section =: also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence orcompliance,viith theidsura*' overage required.
Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliirrce�with the insurttice requirements of this chapter hay
been prettrited to the contracting authority. • -: ~,� :., i' ..> . ;1:
t� •'� �� .� yam•
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affidavit should be returned to the city or town that the application for the permit or license is being requested.
not the Department of Industrial accidents. Should you have any questions regarding the "law" or if you are required
to obtain a workers' compensation policy, please call the Department at the number listed below.
City or rovrns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas
be sure to fill in the permitnicense number which will be used as a reference number. The afodavits may be returned to
the Department by: mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions
please do not hesitate to give us a call.
address.
and fax number.
The Commonwealth Of Mstssxcsuietts
Department of Industrial Accidents
tl cI d Imstltatlon
600 Washington Street .
Boston, Ma. 02111
fa: q: (617) 727-7749
phone fl: (617) 7274900 ext. 406, 409 or 373
BUILDING
TOWN OF Y A R M O U T H ELwmcAL
GAS
1146ROUTE28 SOUTH YARMOUTH MASSACHUSEM026644451
Telephone (508) 998-2291, Ext. 261 — Fax (508) 898-2965 PLUMBING
SIGNS
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL 'AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris esulting from the proposed work/demolition to be
conducted at 27Z
ark Addrew
is to be disposed of at the following location: �T� 0 • \u-'�Q'� ��� -O 1�6�
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Applicant
Permit No.
Date
s BOARD OF BUILDING REGULATIONS
w License: CONSTRUCTION SUPERVISOR
Number. CS 027M
Birthdats: 03114/1934
Expires: 03/1412005 Tr. no: 17751
Restricted: ' 00
RODNEY P ANDREWS
1647 LOWELL RD
CONCORD, MA 01742
' ,� ✓he Contmuneeaal(�i o/'..i�alure�iuJt(Is
-= Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 113772
Expiration: 7115=7
Type: Private Corporation
w
License or registration valid for lodlvidul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston, his. 02108
ANDREWS GUNIiE CO.. INC.
RODNEY ANDREWS
6 REPUBLIC RD Ti - ,r�rc.,i
N BILLERICA, MA 01862 Administrator Not vall without a4tum
.i 7;•�.v.q.y; �•�P ..J �'fY"+P "Lr'Y..'o.�(! � ti It � - t 7��.. ..�` .. �, i ,r.�V.':"' . �' _ ..
CORD_ CERTIFICATE OF LIABILITY.INSURANCE 0 03/03 a5
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Xittredge Insurance Agency Ina HOLDER.THISCERTWICATEDOES NOTAIAEND,M END OR
155E Otis St., P.O. Sox 1=9 ALTER THE COVERAGE AFFORDED BYTHEPOLICIES BELOW.
Northboro MA 01532
Phones 508-393-7744 Paxs508-393-6983 INSURERS AFFORDING COVERAGE NAIL#
m3URED WSUREAA.- Acadia Insurance Company
AnA eeww 1gc iRtedCo., Inc. VISURERC
North Billerica XX 01862 ELwRaTc
wsullEa E:
COVERAGES
THE POUOES OF NSURANCE USTED BQJ9W HAVE SEEN ISSUED TO THE NO1REp WAM ABOVE FOR THE P'OUCY PEW00 WOIGATM NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONDUCTOR OTHER DOCUUW WITH RESPECT TO WHCH THIS CERTFICATL MAYBE ISSUED OR
MAY PERTAW. nE INSURANCE AFFORDED BY nE PONCES DESCRIBED HERSW D SUBJECT TO ALLTHE TEAMS. E= l 310W ANO CONOnXW OF 3ucH
POLICES. AGGREGATE ULM SHOWN MAY HAVE BEEN REDUCED BY PAID CLAWS
R
IN
MIURA
POLJCY NUMBER
( DST AIA00
RAnom
DATE
LIMITS
A
X
GENERALLMB47TY
X COmmERCMLGENERALLMNLDr
CUUMS MADE XX OCCUR
CPA0136208-10
03/01/05
03/01/06
EACHOCCURPENCE
s 1000000
►REMISE31E,omrwrz�1 IS250000
LIED ExP Wry vw oerw) IS5000
PERSONAL A ACV KJURr ISIDO0000
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WORKERS COMPENSATION AND
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEIYCLESI EXCLIRIDNf ADDED BY LOORMUMT13FE UL PROV00N3
OPechee Construction Corp. is included as Additional Insured with respect to
General Liability and Auto Liability as required by written contract.
OPSC:O01 I SHOLU ANY OFTHE ABOVE DESCRIBED►OLK= BE CANCELLED BEFORE THE OVNwTIOHI
DATammoF,THELSSuWGNgAtzm YILLENDEAvORTDMAL 20 DAYS WV=EN
NOTICE TO THE CERTIFICATE NOLO[R NAMED TO THE LEFT, BUT FALUAR TO DO BO SMALL
"POSE NO DBLIDATEON OR LIASSlTY OF ANY 10O WON THE NSUITEIT, rTs AGENTS OR 1
ACORO 25
Building Site Location:
TOWN OF.YARMOUTH
BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
TRANSMITTAL SHEET
27-7
v Tl-i ,
Proposed Improvement:
Applicant:
Address: LC l\E V 13C \
ROeE 1J�
� LV-1__4
g� `J•w , `,PCs\OYAN All
No: 2 6 Lot No: IV
r0 1 ate Filed: I ��
The Building Department will be responsible for assisting the applicant by dispatching your plans and or application to the follow
applicable departments.
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Ads; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Eta
REVIEWED BY:
1. WATER DEPARTMENT; �J�DATE: %1/O N/A:
z DATE: N/A:
DATE: N/A:
4. DATE: N/A:
INDUSTRIAL AND/OR COMMERCIAL PERMITS
S• DATE: N/A:
6 DATE: N/A:
7• DATE: N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE:
White copy -Building DcM • Pick copy - Wata Dept - Ydlow Copy - l lealth Dcpt - Pink Copy- EnBnee+ing Dept - Goldenrod - Fim Dept/Concavation
TOWN OF YARMOUTH
HEALTH DEPARTMENT W [, L G 0 W[ D
PERMIT APPLICATION SIGN OFF TRANS �HEET 2005
HEALTH DEPT.
To be completed by Applicant:
Building Site
Proposed Improvement:�ro����-+.moo. t_
**Ijyou would like e-mail i
Owner Name: 4�;7 t w'
Owner Address: 2'
No.: 2Co Lot No.: 121
�44'h N f,4SATi 16 Tel. No.: 1900 aq
64F6Z Date Filed: /0
oftgn off, please provide e-mail address.
Owner Tel. No.: 5bA- 790 --1 `17 l
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit four (4) copies of plans, to include:
(L) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed);
(3.) If necessary, Title 5 application signed by licensed installer
,-�with fee.
REVIEWED BY:
COMMENTS/CONDITIONS:
TE: /0 / l-�
�1- �1,►c'i-tt�i ,
TOWN OF YARMOUTH
/ ®rz,&P�Building Department
Town Hall
Yarmouth, MA 02664
(508) 398-2231 94261
BUILDING PERMIT
TRANSMITTAL
Temp Permit No.: T-06-209
Applicant Name: Ralph Sabatino
Applicant Phone: 8002727946
Building Location: 00277 SOUTH SHORE DR
Owner's Name: SILVIO V DIGIOVANNI
Owner's Addres 00277 SOUTH SHORE DR
South Yarmouth MA 02664
Owner's Telephone: (508) 398-9556
(OFFICE USE ONLY
Recorded By:
IC
Permit Fee:
$0.00
Deposit Rec:
$25.00
Payment Type:
Check ChkNo.: 5169
Net Owed:
($25.00)
Application Date: 11l7/2005
Issue Date:
Expiration Date
Comments: Map/Lot: 026.127
install inground pool
ZONING APPROVED,.
11l�/�
REVIEWED BY:
1. WATER DEPARTMENT: DATE: N/A:
2. ENGINEERING DEPARTMENT: DATE: N/A:
3. CONSERVATION: DATE: /A:
4. HEALTH DEPARTMENT: DATE: WA:
5. BUILDING DEPARTMENT: DATE: N/A:
6. FIRE DEPARTMENT: DATE: N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE:
Date Printed: 11/9/2005
i
.a
e
I .
'
/3 BARS O '3) /A BARS CONT
.. `�
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OZ. BOTH WAIS r-0' N BOND ft� WATER LEVEE.
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ELEV - O
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9'•—
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(3) BARS O 6' D.C./ — ELEV - 8'-O'
)
.�
CUT OFF AS NOTED 1
2' CLEAR /`—^`CJl OFF
COVERAGE J
ALT. BARS
EXPANSIVE SOIL WALL SECTION
•
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(3) II BARS COW
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13 BARS O IY _ r _
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(3) BARS O G- O.C.
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.CUTI"
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to
AREA BELOW RAND
b
LINE TO BE EXCA- r r
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VATED BY HAND.
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ALT. BARS
/3 BARS O 1. O.C.
BETWEEN CUT OFF LINES
•
EXISTING OR A53WED FOOTING
SEARING 10001 PST.
J-O' MN FaOM POOL
J TTN rr—J- .' N J.:.I7 9EA•1
�_ WATER LEVEL
ELEV a O-0'
ELEV - r-0•
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. 7-0'
— -1-
- — ELEV a 3-J'
Y3 BARS O M_ELEV
O.C. BOTH WAYS ~• 10 }
- _
— ELEV - 5'-0'
ELEV - 6•-0•
(3) BARS O 6' O.C. . ' ♦• '•y -._± __
_ —ELEV 7-0•
M OFF AS NOTED - \_�!
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ELEV . 8-0-
7' CLEAR •� I
COVERAGE
�_Lll OFF
ALT. BARS
� _
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t%OUNDATICN SUrcC::.:RGc
iUaL_ SECTICN
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10 5/85/80
N
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7 I/2•
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9 1/4'
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LEAK'
FLANGE
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SKIMMER DETAIL
N.T.S.
OELK
13 BARS O I•r
(3) 14 BARS
O.C. BOTH WAYS r-D' �• O.C. (CONT) WATER LEVEL
ELEV . O-0'
bay -T-O•
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- — ELEV a 3•-O-
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UNDISTURBED 1
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(3) BARS O 6. O.C.
)
CVr OFF AS NOTED
`OP FLOOR RENF. - Y 3 BARS
20 CLEAR
Otr O.L. (BOTH WAYS)
COVERAGE
NOTE: OPIENSE7<•I9 SHOWN ARE THE maw REOLAZED
AND MAY BE INCREASED TO SLIT CURVATURE OF POOL,
DEEP END RAMP OR W FILL WALL 5ECTiCN
N.I.S.
CONCRETE DEQI
WATER LEVEL
I
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a
(TO POWER 50LRTCE
BY ELECT. COFliR) -,
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UNDERWATER LIGHT CETAIL
NTS.
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FLL SPOUT W/ AR GAP
?I
^1
WATER LEVEL
- CUN1E
STRUCTURE
FILL SPOUT DETAIL
N.T.S.
Ewl"I-' m
FOOTER 1
U •Ci/!1
v
WATERPRGTF
PLASIEi
ENTRE PDX
1
STANDARD WALL SECTION
N.15.
v'E PLAs a Au
,_ � SU:FACES
i3 yA2S 2 6'
•:C BOTH WAYS
!LTC^.AL MC'E:
a AC•EAS ctsQ ATED
•rrATse'r.w.E• BY
C.trNG Xv*04 A
0" 3Rrvl"iC RELFF
vA.LV14;-" BE
LIST &'jo.
TOP .,F
BOND t.A"
5' MN
FLOOR
r�
MAIN DRAIN DETAIL
NTS
DRAW
POOL SECTION
N.T.S.
A CRQA.D WATER 3
ENCOUNTERED NSTALL
Nf"051ATIG RELEF
YALN: AS PER NFCR
N EACH 5' iP
ALL SURFACE WATER
SHALL DOAN AWAY
FROM POOL
GENERAL NOTES
• CONSTRUCTION SHALL CONFORM TO CITY DEPARTMENT OF BLOC
& SAFETY CODE & STANDARDS.
• DIVNC BOARD NOT PERMMTED ON POOLS LESS THAN SEVEN FEET
N DEPTH AT BOARD.
• HEALTH DEPARTMENT APPROVAL REOLARED FOR ALL
COMTIERCIAL TYPE POOLS.
• ELECTRICAL SHALL CONFORM 10 LOCAL CODE REOMEMENIS.
ELECT. NSPECrION FOR CROLI DNC OF REINF. PRIOR 10 CUN1E.
DESIGN NOTES
• 114ESE DESIGNS CONFORM 10 LOCAL CODE AND BASED IRON A
REASONABLY LEVEL SITE AND APPROVED NATURAL C20J D WITHIN
TWO FEET OF TOP OF BOND BEAM (EXCEPT AS SHOWN). ANY
DEVIATIONS FROM THESE CONCITONS WLL RECURE SWPLEMENIARY
06TALS AND CALOULATIONS.
• NO C20UrD WATER SHALL BE AT P00. LEVEL.
FENCE NOTES
• OWNER SHALL PROVIDE KNOX N COMP•LIANCE WITH LOCAL
CODE REOLI2tmws PRIOR 10 OCCUPANCY.
REINFORCING STEEL NCTE5
• REINFORCYJG 57EEL SHALL CONFORM TO Ar.131. PE51CNAT045
A-15 AND A-305. LAPS SHALL BE A MW M OF 30 CW*IERS
OR 60 WFERE SPLICES OCCUR.
GLUTE NOTES
• CUNITE SHALL BE MACHINE MTxED AND APPLIED PNEUMATICALLY.
rlX SHALL Be ONE PART CEMENT TO FOUR AND A HALF PAR15
SAND (I : 1 1/2) LLT. COMP. SIRENGTH OF 2000 PSI
AT 26 DAYS.
• WATER CEMNT RATIO SHALL NOT EXCEED 3 1/2 . ALLONS OF
WATER PER SAC: OF CEMENT.
• CURE G11NTE BY' A WATER FOG SPRAY THREE TM5 A DAY FOR
FOUR CONSECUTIVE OAY5 I VOI11 T.
SPECIAL N07E
• FOR COMr*2C1AL POOLS ONLY: A 12ADIL6 OF "-9' AND MAX
VERTICAL WALL OF 7-0' 15 PERMSSABLE FOR ABOVE 5ECION3
(CONSERVATIVE). SPECIAL DESIGN 15 RECLARED WHERE FILL
ExCEEDS 7- .
L
r EA151MI; v
FOOTER
POOLS by
ANDREWS N. Bq ERICA,MA 0�62
QuwrE COL ma
STANDARDSW(rrlNG POOL,\,F\OR:
NAME: AR
Z%% p' 6L.\'a _ Y�rt
ADORESS-Z�%CrIaA.JFE1Vf�t i
(SE ALSO DETACHED PLOT PLAN DRAWING)
0
1NNOTES
1. LOCUS Is A.M. PARCEL 127.
Z ZONES
SHORE ppl
SCALED FLOOD ZONES ARE FROM FIRM DATED JLX.Y Z 19BZ 11
3. OFFSETS SHOWN ARE TO THE CORrERBOARDS ON E)USTMlG �•�
BUILDINGS. DINGS• OR M FOUNDATION ON NEV CONSTMJC bL
sou
, f ,
I CERTIFY THAT THE BIALDNG LOCATIONS N
SHOWN ON THIS PLAN WERE MEASURED N
THE F�/05 R 10/0
6
/05.
tN0F ,�. .
1, A ►�.
J
•0' 46
\ P� --.BUILDING. zoo
!G NO. 277 z�r
N/F TOWN
OF YARMOUTH
LAND HERE I
MAY
BELONG TO
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PROPOSED 20' X 40' POOL PROP. w N/F
d BLUE WATER LTD
11
PARTNERSHIP
_ APPROX. 1930 SHORE —� — — _. —— O
370rt I to
I
a -MID fLOpp D1 M �� I• �
SGL[D ROW M %13
FROM ASSF�ORS MAP
APPRO%. 511GRe — — — — — ASBUILT PLAN
FOR
SILVIO V. DIGIOVANNI
277 SOUTH SHORE DRIVE, SOUTH YARMOUTH
NANTUCKET SOUND OCTOBER 8, 2005 SCALE. 1*=W
RONALD %L CAI LLAC PM IRS
PRGFcssom LAUD SLR%t-M ! FAMMTU0 SANTARUW
PA SM 25B v 1
rIEST YARMOUTH, MA
REV. 10/17/05—ADD PROPOSED POOL. SHED -c FENCE 02M5 BY RACAMLAC
1 pU'.G;�iGUcPj.
�o4•VTOWN OF YARMOUTH
o� _G BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, R NIA 02664 508-398-2231 ext. 267
DIRECTIONAL SIGN APPLICATION
Date: 12/1/2002 Permit No. 35
Application Is hereby made for a permit to maintain and advertising sign, so called" Pubic Information Sign% in accordance with
Sec.8,Chapt85 of the General Laws.
RENEWAL FEE: $10.00
Payable upon receipt
PERMIT EXPIRES: 1-02-2004
Permit is issued pursuant to Yarmouh Sign Code, Art 303;sec.3.2.1 shall require a permit to be issued by the
Building/license Dept. In accordance with Chapt85 of General Laws.
These will be limited to a, mabmum size of Five and one half by forty inches and will include only identification of business.
The lettering will be black with background. These signs must be placed on racks in locations approved by the Yarmouth
Department of Public Works. An annual fee, determined by The Board of Selectmen may revoke any permit at any time, for
any infraction of the regulation.
BUSINESS:
Surf & Sand Ocean Front Motel
LOCATION:
South Shore & Sea view Ave
WORDING:
Surf & Sand Ocean Front Motel
OWNERIMANAGER: Sandra Di Giovanni
ADDRESS: 277 South Shore Drive South Yarmouth, Ma 02664 Phone: 508-394-3700
MAIL ADDRESS: P.O BOX South Yarmouth, Ma 02664
9 17
6l1 CA G�
Signature of Person, & authorized agent, to Title
Whom permit is to be granted. / ) ^ /
Date
Please Note:
1) Application form must be submitted for each permanent sign.
2) The Building/license official shall be notified within ten (10) days of any change in the above information.
}oF Yk TOWN OF YARMOUTH
G BUILDING DEPARTMENT
�... 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 267
DIRECTIONAL SIGN APPLICATION
Date: 12/1/2002 Permit No. 36
Application is hereby made for a permit to maintain and advertising sign, so called' Public Information Sign% in accordance with
Sec.8,Chapt.85 of the General Laws.
RENEWAL FEE: $10.00
Payable upon receipt
PERMIT EXPIRES: 1-02-2004
Permit is issued pursuant to Yarmouh Sign Code, Art 303;sec.3.2.1 shall require a permit to be issued by the
Building/license Dept In accordance with Chapt.85 of General Laws.
These will be limited to a, mabmum size of Five and one half by forty inches and will include only identification of business.
The lettering will be black with background. These signs must be placed on racks in locations approved by the Yarmouth
Department of Public Works. An annual fee, determined by The Board of Selectmen may revoke any permit at any time, for
any infraction of the regulation.
BUSINESS: Surf & Sand Ocean Front Motel
LOCATION: South Shore & Sea View Ave
WORDING: Surf & Sand Ocean Front Motel
OWNERIMANAGER: Sandra Di Giovanni
ADDRESS: 277 South Shore Drive South Yarmouth, Ma 02664 Phone: 508-394-3700
MAIL ADDRESS: P.0 BOX 370 South Yarmouth Ma 02664
r&vm6F--I' CAA. 6 M
ire of Person, o authorized agent, to Title
permit is to be granted. /a- /f 63
Date
Please Note:
1) Application form must be submitted for each permanent sign
2) The Building/license official shall be notified within ten (10) days of any change in the above information
4-
TOWN OF YARMOUTH
BUILDING DEPARTMENT I I�.,, vl%1�V
1146 Route 28, South Yarmouth, h1A 02664 1
508-398-2231 eit. 261 Fax 508-398-0836
January 21, 2004
RE: 277 South Shore Drive/Sand & Surf Motel
To Whom It May Concern:
Mr. Will Penrose and Ms. Karen Carmona have this date requested a zoning determination with
respect to a continued use of a jet- ski rental operation at the above referenced location.
Please be advised that the proposed use is permitted as accessory to the primary use as prescribed
in Board of Appeals Petition No. 3252, dated December 14, 1995.
Very truly,
James D. Brandolini, C.B.O.
Building Commissioner
TOWN OF YARMOUTH
BOARD OF APPEALS
DECISION
FILED WITH TOWN CLERK: DEC 2 7 1995
PETITION NO: #3252
HEARING DATE: December 14, 1995
PETITIONER: Silvio V. DiGiovanni
c/o Philip E. Magnuson
255 Main St.
Hyannis MA 02601
PROPERTY: 277 South Shore Drive, South Yarmouth MA
Assessor's Map 22 Parcel T119
y DEC 27 P12 c3t/
u;::t
IUWN CLt:ittt iki
MEMBERS OF THE BOARD PRESENT AND VOTING: Jerome Sullivan, Acting
Chairman, John Richards, James Robertson, Joseph Samosky, Andrew Ryan.
It appearing that notice of the hearing has been given by sending' notice to the petitioners and all
of those owners of property deemed to be affected thereby, and to the public by posting notice of
the hearing and published in The Register, the hearing was opened and held on the date stated
above.
Attorney Philip Magnuson presented the petition to the Board. Mr. Magnuson was accompanied
by Mr. Silvio DiGiovanni, the petitioner. Mr. DiGiovanni is the owner of the propertyin .question
which is the site of the Surf and Sand Motel Resort. The Surf and Sand Motel is a pre.existing,t
el'which has been in operation for over 30 years. The locus consists of 3.35
acres with approximately 350' of shore line along Nantucket Sound. It is located in an R25 zone.
The petitioner requests to ovieifum--the:deaisioa=of_the: Building Inspector dated October 17,
1995, that aquatic recreational activities are not accessory uses to the existing motel use at the
Surf and Sand, or in the alternative a Special Permit to allow those aquatic rccLeation tiYitie -�
including-parasailing,-banana_boat:sides;-and-wind surfing:- These activities will be offered
primarily to motel guests but would also be'.availahle fob lncidental_use_by-non=guests which will
ik. ude gnesti. o el customers. -Any such non -guests will be required to register with the Surf
and Sand and receive a Registered Guest Pass to use their facilities. The petitioner will maintain
sufficient supervision so as to be sure that these activities do not interfere with or detract from the
principal motel uses. All of these activities will primarily take place out on the waters of
Nantucket Sound using the beach front only as a starting point. The pick up boats will come to
the beach through a marked safety zone to pick up and discharge passengers. There will be no
on -premise sign advertising these activities and no increase in parking demand is anticipated.
No one in the audience appeared in favor of or in opposition to the petition.
The Board received correspondence from Forrest White, Building Inspector, referring to this
application and informing the Board members of a previous decision by the Chatham Zoning
Board of Appeals, a memo from the Planning Board, letters from two town residents in
opposition to this petition, and comments from Linda Sears, Recreation Director for the Town of
Yarmouth with respect to concerns for the safety of swimmers in the public beach area and
requesting marked access lanes for the boats used to pick up and discharge passengers at the Surf
and Sand beach area.
The Board was, satisfied that granting the requgted-Special Pm *t,will not create�ny lue .i
uisance;�liazard; or congestion,•and•that there.wilLlze 09 s1ilitan
_.._1W harmAo_tha-established or
future character of the neighborhood nor of the town. There was general agreement that such
activities would be an allowed use, incidental to the principal motel use.
Accordingly, after further dehberations, a Motion was made by Mr. Robertson, seconded by Mr.
Ryan, totoverturn:the decision:of the.Building:Inspector.regarding.the-accessoryuse and'such
Motion finds as an accessory use permitted by the by-law the three activities requested (i.e.
parasailing, wind surfing, and banana boat rides) and to •b�Lpcnzitted_accessory�iises to-6W
primary use of the property which is a waterfront motel, including their incidental use by
registered day -guests. The vote was Mr. Sullivan, Mr. Robertson,•Mr. Richards, Mr. Samosky,
and Mr. Ryan in favor. The vote was unanimous.
Appeals from this decision shall be made pursuant to c4OA §17 and must be filed within 20 days
after the filing of this noticeJdecision with the Town Clerk.
Special Permits shall lapse if a substantial use thereof or construction has not begun, except for
good cause, within 24 months of Special permit approval (exclusive of time required to pursue or
await the determination of an appeal referred to in MGL c4OA §17, as amended) from the grant
thereof.
OFFICE MEETING NOTES
ADDRESS: �7 %? ,I /ar, ., - DATE:
Names of Attendees:
Zoning District:
Flood Zone:
Meeting Topic:
X -74
3�j
f
S
3 C�? ,-- I:)
/'0,- Z��
PLUd with Tom Clerk: OCT 8 1962
Petitioner: Donato J.,IhNuis
TU-L OF V41MUM
DUA11D .UF AI 1VdS
Hearing Date: Septembor 6, 1962
Petition 111raber: 587
The petitioner requested the apr;roval of the Board of Av, pxals to' allotr the erection of 14
units additional. to the Surf & Sand Mtel, Base I;i.vor, . wasoor's 11ap 223, Parcel T119.
IkMbers of Board of Appeals proaent:
Albert :;ebb
Alex. Catto
Stuart Ibder
Paul. itebber
Iurold Ls JhWess Jr
It aunearing that notice of said hearing has been given by sending. notice thereof to the
Petitioner and all those owners of property deeded by th3 Board to be affected
Standard Times on and that publio tine Augustof 1s� hearing having been given by publication in U:o Cape Cod
above written. ¢ �, 1'e beg was opened and bald on the date fast
The following appeared in favor of the petition:
Donald J. I:arquis
Sally Ibiquie,
Cara Burch
Walter B. iti]].iaam >
She fO lawI09 appeared in oppositions
Hufte
Reason for Decision: It appeared at the hearing that th i rocPMt was for an —adili 16,1 to
the 6XISting Surt & Sand :label located an South chord Derive in Bass River. IL t r�
appeared that Original plans called f= the unite requertod but their:woro not built at the
Of QrI9LWI
and baCMWUWUM. VA addition would be can the %=terly side of the a�dst3n aotel
In loeo dug tida h the decision on -of tho prosenti' gotel etructum, .
l! <ida1that, all the �a Of the coning by -a* r would be met lnabtuling setback
�9 further appeared there was adgluste parking to accas:adate addition
guests at the patituclerls motel location.
The board found that the Public good .would not be adveracty affactod by granting this pit
and umimously granted the request as set forth in tho pctttion.
11=%bers of Board voting:
Albert Hebb — In favor
Alan Catto In favor
Stuart Drier — 7nthvor
Paul Umbber - In favor
Harold L.. IkWwo Jr. — in favor
z=sIssued until upetiti oa for appa�val is granted cal the foil,wdng c onditiona t No permit
days,tin date of decision.. r
• Hsj Jr.
TOWN OF YARMOUTH
BOARD OF APPEALS
APPEAL OF ESTHER R. gam),. OREY HIRSCH
March 6,�952t
Appeal No. 199
The Petitioners are asking for approval from the Board of Appeals for
permission to build a Hotel on South Street, Bass River.
This is contrary to the zoning by-laws in that Paragraph 11, Section 2
requires the approval of the Board of Appeals.
Members of the Board of Appeals present:
Elwin W. Coombs, Chairman
John E. Harris
Alexander Catto
Fred M. Angus
H. Stuart Ryder, Associate
Thomas Matthews, Associate
The following appeared in favor of the Petition:
Daniel J. Fern, Representing the Hirschs Mr. and Mrs. W. Lawrence Prince
Mr. Bluecher Jack Culley
Mr. Skolnick E. J. Particelli
Mr. Sias Edwin G. Romer
Arnold T. Booth Mr. and Mrs. Hubert Glendon
The following appeared in opposition of the Petition:
Mr. and Mrs. Earle Fox Mr. and Mrs. Herman G. Curtis
Helen MacKenzie Helen Gonsalves
Myrtle Breed Myrtle Mehaffey
Haydn Mason Herbert Foster
Elizabeth Hussey Edward Ambrose
Theodore Frothingham Mr. Gill
Eleanor Lay
Daniel Fern: (Representing Esther R. Hirsch and Morey Hirsch) Presents plan
of the land and proposed hotel ih question to the Appeal Board members, showing
its dimensions and the street on which it borders and indicating it as a parcel of
land roughly 300 feet on the street, 382 feet on the East side and 435 feet on the
West side, and 300 feet on the rear
i
It is proposed to: -Hote3pthough it would not be as pretentious as a Hotel
in the usual sense.Presents sketch prepared by Mr. Richard S. Gallagher, Architect.
Sketch is for eighteen rooms, let class appearance. It will be an a sit -BCD the
community. Piece of land located on what has been for many years a emi-commercial
location. It was originally a part of the Casa -Madrid development. �'Ae abutters
on either side have been and are now engaged in business allied to what is sought
to be dono here. Is Chairman of the Board of Appeals in his Town. Falmouth has
had developments similar to this and they all reflect great credit to the community.
This Hotel and property will cost Z100,000. and will add substantially to the taxable
income for the Toim. Hotel will be operated in a first class manner and work would
Page Ii
TOWN OF YARMOUTH
BOARD OF APPEALS
Appeal No. 199
commence as soon as the ground permits.
Richard S. Gallaghor: Explains floor plans in detail to Appeal Board members.
This proposed building consists of eighteen units, eight on ground floor, breakfast
terrace, snack bar, lounge, office, service room and lobby. Ground is level and
goes back on dune and they propose to put building there. Each bedroom to be
12 feet x 15 feet;y 4 inches. The rooms will be so that the beds can be made up in
the day and used as a sitting room, on the Statler idea. The applicants, if Board
permits, intend to build I of project. Are there any questions?
Fred Angus: What is the construction of this Hotel?
Richard S. Gallagher: Concrete block and wood frame. Located well back from street.
There will be a single exit to and from the street. Parking for twenty-six cars in
an organized parking spaco. Road could be widened.
John E.
Harris:
Two
stories?
Richard
S. Gallagher:
Yes.
Daniel Fern: Parking will not be a burden on the Town as there will be ample room
for off street parking, more than is reasonably necessary. There will not be a traffic.
hazard. Land has been unimproved for many years and value is such that land is not
for private residence particularly where area has been developed upon similar lines.
Upon tir. Coomb's request persons in favor stood up and named themselves as being in favor.
Xr. Fern shows and explains the plans to people opposed. .
Haydn Mason: I would like to ask a few questions. First.if you grant this approval
what guarantee do we have that the building will come up to the appearance of the pictures
Elwin Coombs: We have a Building Inspector whose duty it is to see that the building
conforms to the plans presented.
Haydn Mason: You say, Mr. Fern, that this building will cost 6100,000.00. Will
your clients agree to 19 assessment of $100,000.00?
Daniel Fern: Would you be willing to sell your property for the amount it is assessed
for?
Elwin Coombs: I think that is a very good answer.
Mr. Gill: I understand application was made to the Board of Selectmen. Why did they
deny this application?
Elwin Coombs: This is an automatic procedure.
Reginald Love: Anything rather than a one or two family dwelling on a lot is
automatically rejected by the Selectmen.
0
a - . f
III
TOWN OF YARMOUTH
BOARD OF APPEALS
Appeal No. 199
Mr. Gill: Mr. Fern called this building a Hotel. Is it a Hotel or is it
something else?
Elwin Coombs: As far as this Board is concerned the petition is for a Hotel.
Webster's Dictionary defines a Hotel as a place where lodging can be obtained.
Daniel Fern: The Supreme Court has no definito definition for a motel. It
will be a hotel on a limited scale, unlike city hotels. Not with as many services
as in a city hotel but with services expected in a summer resort area.
Mr. Gill: Is this Hotel to be constructed for summer use?
Daniel Fern:
For summer resort use only.
Mr. Gill: Is there to be a bar in this building?
Daniel fern: It is not contemplated. -
Herman Curtis: We have had some trouble with a motel in this particular section.
Believes that this particular building is not a hotel.
Daniel Fern: The lay -out and appearance will be as indicated and as Mr. Coombs
explained your Building Inspector will see that the finished job conforms.with the
plan. As -far as having a Bar is concerned, we could have all the intentions in the
world but any such application would have.to come before another Appeal Board and
have approval up in Boston. We have not made any such plans. There is no hard and
fast rule as to what is a Hotel and what is a Motel.
Mr. Gill: Mr. Fern said eqrlier that this vicinity is semi -commercial and named
one case, the Casa -Madrid. This development certainly is residential. A great mapy
people have invested money in that neighborhood and being away, scattered all over
the country, do not know about this petition.
Elwin Coombs: Under this petition for approval the abutters do not have to be
notified.
Mr. Gill: You should still consider their wishes. I know 'some people who would
object if they knew.
Elwin Coombs: This petition was advertised in the paper and if people are interested
they will come a great distance. Thinks the Board has acted in a fair manner.
Haydsi Mason: The building laws allow one and two family dwellings in that district.
The Planning Board must have had a very good reason for limiting that part of Town to
one and two family dwellings. Do not see why we should allow a variance and change
the law because someone comes along and wants to put up a $100,000. building. These
laws are for the good of the neighborhood.
IV
Mr. Coombs:
TOWN OF YARMOUTH
BOARD OF APPEALS
Appeal No. 199
Reads Paragraph 11, Section 2 of the Zoning By -Laws.
Elizabeth Hussey: I do not think this building is a hotel. A motel is a
better name for the plan I have seen.
Elwin Coombs: Since Superior Court has not defined what a Motel is I hardly
think this Board can. The Town, through the Planning Board, will have to make
its own definition of a motel.
Eleanor Lay: Everybody goes by what they see and it looks like a motel. We
have been against motels all winter.
Earle Fox: Whether or not there is any legal definition of Motel I think the
Board should consider the community in making their decision and think of the future.
Elwin Coombs:. If we approve it will be on the basis of a Hotel. We cannot disapproc
on the basis that itis a motel. Do you honestly think we could call this a motel?
Elwin Coombs:
Responses of Yea.
Until it is legally defined we cannot.
Haydn Mason: You and I know, as 999 people out of a thousand would know, that
this is a motel and the Zoning -By -Laws do not permit a Motel.
Daniel Fern: There were nine people who came and inspected the plans. The objection
have come from people who did not even bother to do so. Seems to me that protracting
this too long is not fair to people who do have some constructive objection. The
objections so far have been with the Zoning By -Laws but that is not the fault of
your Board or of the applicants.
Mr. Gill: It is a waste of time arguing over the definition of motel and hotel.
Each member of Board should use his own best judgment and apply common sense and
decide in their own minds whether it is a hotel or a motel. If it is a motel you
have no right to grant variance.
Mr. Coombs then called on those in opposition to stand up and name themselves as
wanting to be recorded as being opposed to the granting of the petition. These persons
are listed on the first page of the minutes.
Elwin Coombs:' .de have heard from those in favor and those in opposition. Knowing
this petition was coming up we have been trying to find out a definition of these
two words but in lieu of the fact that we could not find a definition of a motel and
since this plan is for a hotel we will have to consider it as such.
Mir. Gallagher leaves the Hearing.
J
v
TOWN OF YARMOUTH
BOARD OF APPEALS
Appeal No. 199
Daniel Fern: Does not believe Mr. Gallagher has tried to put over anything on
anyone. He is as vitally interested in good construction as anyone in this room.
He has erected a large number of modern homes, my own included. This is a modern
hotel. The people who should be mostly concerned are the immediate abutters. They
have not objected. In fairness to the applicants, they have spent a great deal of
money in employing an architect'who is familiar with your needs and requirements
and have invested substantially in land which has not been used before. In fairness
you should grant application.
Earle Fox: We do not want this district to be commercialized.
Mr. Gill: I believe I represent one hundred property owners and summer people
and if they were contacted they would want to be recorded as being opposed.
Hearing, Closed
The following vote of the Board of Appeals was taken:
Elwin W. Coombs
John E. Harris
Alexander Catto
Fred M. Angus
H. Stuart Ryder, Associate
Thomas Matthews
(Unanimous in granting petition)
Therefore the Petition for Approval was granted on the following conditions, viz:
That approval for a hotel is on the basis of plans and elevations indicated and
offered at the Hearing.
TOWN OF YARMOUTH
BOARD OF APPEALS
Appeal No. 231
A meeting of the Board of Appeals was held in the Town Office Building on
Thursday evening, October 16, with the following members of the Board
present:
Mr. Elwin W.Cbombs
Mr. Thomas F. Matthews
Mr. Richard E. Robsham
Mr. Alexander Catto
Mr. Fred M..Angus
Mr. Coombs read the petition of Mr. Donald G. MarquisA ow --the,
wilding of a -motel on South Street, Bass River. It was stated-ttiat
some time ago was granted to a Mr. Hirsh for this same
location. Mr. Hirsh sold the property to Mr. Marquis and since the
variance runs to the owner and not the property it was necessary to
make a new appeal.
Mr. Castonguay represented Mr. Marquis, who was also presents and
stated that Mr. Hirsh had obtained a permit w4ich was not the same
as a variance because it does not require notice to abuttors. It
was therefore deemed advisable to go through the proper procedure so
that everyone would know what was going on.
Mr. Marquis presented an architect's sketch and site plan showing the
lot as 300 febt on South Street and 385 feet deep to the ocean and 370
feet ocean frontage. The building will contain 22 individual units,
lounge room and owners quarters. The plan is substantially the same
as the one offered by Mr. Hirsh in March of this year.
Recorded in favor: Mr. Frank Williams
Mr.
Leonard Burch
Mr.
Hubert Glendon
Mr.
Frank E. Riley
Mr.
Robert Johnson
Mrs.
Mullen
Mr.
Herman Curtis
Mr.
John Martin
No one recorded in opposition.
Hearing declared closed.
Petition granted.
R (G TOWN OF YARMOUTH
BOARD OF APPEALS
'86 SEP 23 P 3 :04 SEP 2 3 1%6
Filed with Town Clerk , Hearing Date: August 28, 1986
Petition No: 2341
TOWN
Petitioner: Donald Henderson
277 South Sea Avenue
West Yarmouth, M.A. 02673
DECISION
RELIEF REQUESTED
The petitioner har, appealed for relief -in the form of a
'spec3a7: peircilt- accoriiance with Yarmouth Zoning Bylaw Sections
1 3"Z'""`9H_d 104.3.2; and M.G.L. Chapter_:,,40A, Section., 6, .as
amended, to allow; ap.`- additicn,of, a y...residence
(dwelling) above an ex stil5g"boet, house on property located at
277 South Sea Avenue;�Westr Yarmouth, MA., also shown on
Assessor's Map No. 10 Lot Dl. See also .Land Court Certificate
of Title.No::86915 and-tand-Court-Plan No.:.12601A.
PLANS i
The petitioner subbitted a certified plan depicting locus
entitled;' sketch. plan iin West Yarmouth, Mass. prepared for
Donald F. Henderson, seale 'l" = 60', dated April 18, 1986 and
May 6, 1986, by Low andWeller, Inc., 714 Main Street; Yarmouth,
Mass.
HEARING
The Petition was duly filed. Notice was given as required
by law,incl.uding twice: publication in the Register, a weekly
publication having circulation in Yarmouth. Pursuant to notice
a public -hearing was held by this Board of Appeals on the
evening of August 28, 1986. In the *course of -the hearing
_several.quections were posed to the Petitioner's representative
by members of the Board -of Appeals. Several- Yarmouth residents
were heard and response was made by representative of the
Petitioner and by members -of this -Board. = -
MEMBERS OF BOARD -OF APPEALS -PRESENT
David Amon --- —__I.eslip C unphEllL
_FI l t 7 Lind ;, i a M -- Judith --Sall iya[a
Richard Neitz
RECf`/�r� Page 2i
,86 CRITERIA AND AUTHORITY
SEP
23 P R:e4 criteria for the grant 'of this special permit are
;stated -as follows:
Towiq GLEF;F u i F;_,y51 c
3. i•'Zoning By -Law Section 103.2.2: Special permits shall
not be granted unless the applicant demonstrates that no undue
nuisance, hazard or congestion will be created - and that there
will pe no substantial harm to" --'.the established or future
character of the neighborhood or town.
2!. Chapter 40A: Special permits may be issued only for
uses which are in harmony with the.general purpose and intent of
the ordinance or bylaw. and shall be subject to -general or
specific provisions set forth therein; and such permits may also.
impose conditions, safeguards and limitations on time or use.
3. The _change, extension or- alteration of a prior
existing nonconforming criteria are stated in Section 104.3.2'of
the bylaw as follows: -
"Pre -existing non -conforming structures or uses may be
extended, altered or changed in use on special permit from
t�e Board of Appeals if the Board of Appeals finds that
spch extension, alteration or change will not be
s bstantially more detrimental to the neighborhood than the
existing non -conforming use."
FACTS .
i
Petitioner is the owner of a parcel of land containing
140Olvacres. more or less, situated between South Sea Avenue, a
forty foot town way, and -the waters -of Lewis Bay as shown on a
sketch plan by Low and Weller. Inc.. dated April 18, 1986,
revised May 6, 1986. It is also shown as Parcel D-1 on Sheet-10
of the Yarmouth Assessors Maps and on Land Court Plans 12601A
and 14103A. _
Locus -is bounded on the East by South Sea Avenue, on the
South by land of Fields Point Corporation; on the West by Lewis _ -
Bay and- on -the North by land of Virginia Schirrmeister .and Ethel •
C. Morrii3on.
- The cove or boat -basin shown 'on -the --plan, Assessors Maps
and in ..the' photographs presented is entirely on land- of
Petitioner. It was built, pursuant to proper permits, in late
1950s and is used by the petitioner for his own use. Since the
REOF11.1 Page 3
i .
p S 186 23 cggt�a as constructed, petitioner and his predecessors in title
HIV/ JCS hNeO iven the Town of Yarmouth dockage for various Town -owned
patrol craft. For the past several years; at -'least one vessel
..under the jurisdiction of the Harbormaster, and two under the
TOWN CLEitr; L ;iiiri'sdiction of :the Department of Natural Resources, have been
docked in the cove at no cost to the Town.
There are four buildings on the- 14.01 acre tract, a house and
windmill completed in 1929, a barn/garage to the north of the
house built in the late 1940s and added to in the 1950s, and a
boathouse built'in the late 1950s. All four buildings are shown
on the plan and in the photographs submitted at the hearing.
The dwelling is`the principal place of residence of petitioner
and his parents. -
Petitioner -is requesting a -special permit under Section
104.3.2 of the Zoning By=Laws to add a single family residence
above the existing boathouse. The boathouse is approximately
'fifty-two (52) feet by thirty-six (36) feet, and is constructed
on a full poured concrete foundation. It is a one and one-half
story structure with the lower level used for boat storage.
There is a loft, additional storage area and a sundeck on the
upper level. The addition of a residence would 'result in no
change in the footprint of the structure with the exception of
an outside staircase. The Petitioner contemplates raising the
roof of the structure and putting the -first floor of the living
quarters on approximately the- level of the present deck. The
structure would comply with the height requirements - of• the' -
by -law and would be upgraded, where necessary to meet the State
Building Code. The septic system would comply with local
requirements and would be located at least one hundred;'(100).
feet from mean high water. -Complete septage"system plans would
be submitted to the Board of Health at the'time of filing for a
building permit.
Also, a Request for a Determination. of Applicability will
be filed with the Conservation Commission, and if necessary, a
Notice of Intent will be filed with that Board.
The residential use is allowed under the -
boathouse use is also allowed as an accessory use.
= - boathouse is closer. to the water than would be -
current -zoning and thus-is'non-conforming.
by-law._ The
However, the
allowed. under
�-t�; �n Page 4-
R f:; - .
Locus is located in an R-25 zoning district which requires
25 000 quare feet of area and 150 feet of frontage for a
'86 $EPb?Alai%io lot. Locus contains in excess of fourteen (14) acres
and the effect of granting the request would be to allow a total
Tir.;[pf,two -houses on 610,275.6 square feet, more or, less, or one
TOWN CL'EPROPPK'Apoi:.i, 305,137.8 square feet. This would mean that each
house would have in excess of twelve (12) times the land area
that current zoning requires.
Petitioner submits that there will be no impact on the
neighborhood. There will simply be one more single -family
house, an allowed use, on -a huge lot. If the tract were
subdivided, under current zoning fifteen (15) or more lots could
be legally created. However, petitioner does not- wish to
subdivide.
CRITERIA SATISFIED
The criteria as stated above are satisfied based upon the
above facts in that:
1. The requested change, alteration and extension will
not be substantially more detrimental to the neighborhood than
-the-existing nonconforming use.
2._.: No unduenuisance, hazardor .congestion will be
=:created End that there will be no` ubstantial harm to the
:established or future character of the neighborhood or town.
3. The Proposed project is in harmony with- the general
purpose and intent of the bylaw.
CONCLUSION AND RELIEF
The Petitioner is hereby 'jranted a specialpermit for the
construction -and -use -of -a —single`--` miiy"=dwelling as -requested..
subject"to-4thei ►following=condi•tions - - - "
1. The structure shall_ not ---be constructed without -a
subsurface disposal.- system• approved- by the -Yarmouth Board of
Health. -
2. The -peti-tioner shall not sell said dwelling without -
approval of a definitive subdivision -plan- or endorsed ANR plan
by the Yarmouth Planning Board, showing said dwelling on a
separate lot meeting all lot requirements of then existing
Yarmouth Zoning Bylaw,
i
Fage 5
The Decision and Relief herein granted shall run with the
land and enure to the benefit of the petitioner and his heirs,
devisees, successors and assigns.
MEMBERS VOTING•
David Oman Leslie Campbell
Fritz Lindouist _-_Judith Sullivan
Richard reitz r
All voted unanimously in favor granting the Petitioner's
request.
Therefore, the Petitioner's request for. Relief is:granted as
above for all the above stated reasons. _
a
No permit issued until 20 days from the date of "filing the
decision with the Town Clerk. :
Frig 7.inAqnig
Clerk
i
- i
' - c
0
-„
_ M
_ W _
= _
TOWN
1146 ROUTE 28
BUILDING
OF YA R M O U T H ELECTRICAL
SOUTH YARMOUTH MASSACHUSETTS 02664
7cicphunc 1508) 398-2231
BUILDING DEPARTJIEN'f
Atty. Philip E. Magnuson
255 Main Street
Hyannis, MA 02601
Re: Aquatic Activities
277 South Shore Drive
Dear Phil:
GAS
PLUMBING
SIGNS
October 17, 1995
As you know, I have spoken with Mr. D. Giovanni about the
use of aquatic activities at the Surf 'N Sand Motel. It was,
and still is, my understanding that an accessory use cannot be
added to a pre-existing, non -conforming use without Board of
Appeals approval.
In the Davenport decision you referred to, the problem was
that the activities were being rented to the public. A Board
of Appeals decision back in 1980 agreed that these activities
were an accessory use at that time and "they may not rent to
the general public without a Board of Appeals grant".
Non -guests who register with Surf IN Sand to receive a "reg-
istered Guest Pass" enabling them to rent the equipment, to me
is the same as renting to the public.
My opinion is that a special permit is required from the
•Board of Appeals in order to offer these aquatic activities to
guests and so-called day guests to the Motel.
Enclosed please find copy of 1980 decision.
Very ,truly yours.
Forrest E. White
Inspector of Buildings
FEW: des
Enc. 1
xc: Board of Appeals
Jack J. Furman
Robert T. Cannon
Stuart W. Rapp
Philip E. Magnuson
Ana Gomez-Blanchfield
Mark D. Carchidi
Donald H. Mason •
-Aw adimuea in Rai"
FURMAN, CANNON & ROSS, P.C.
Attorneys at Law
255 Main Street
Hyannis, Massachusetts 02601
Telephone (508) 775.-0277
Facsimile (508) 778-4256
Forrest E. White, Building Inspector
Yarmouth Town Offices
1146 Route 28
South Yarmouth, MA 02664-4451
Of Counsel
Diane Furman Ross
Mosca & Associatest
Samuel Lamm tt
September 12, 1995
Re: Request for Zoning Decision/277 South Shore Drive,
Assessor's Map 22, Parcel T119
Dear Mr. White:
This is to follow up on our discussion earlier this Summer about the Surf N' Sand Motel,
and to request a written zoning decision.
As you know, the Surf N' Sand Motel is a pre-existing nonconforming motel located at
277 South Shore Drive, South Yarmouth. Silvio V. DiGiovanni, owner of the Surf N' Sand,
wishes to use the extensive waterfront and adjacent waters of Nantucket Sound for aquatic
recreational activities, including parasailing, banana boat rides, wind surfing, and jet ski use.
These activities will take place on the waters of Nantucket Sound, and the beach used only as
pick up and drop off area. All equipment will be owned by the Surf N' Sand Motel and all
activities conducted by Surf N' Sand employees. These activities will be offered primarily for
motel guests, but would also be available for incidental use by non -guests.
Non -guests will be required to register with the Surf N' Sand to receive a "registered
guest pass". There will be no on -premises sign advertising these activities. The only area of
the premises to be used for such activities will be a small portion of the ample (approximately
400 feet) shoreline where the parasailing boat or tow boat will come to shore to pick up and off
load passengers. Other equipment, such as jet skis and wind surfers, would also be located
along the shore.
Aquatic recreational activities are, and always have been, an integral part of a waterfront
motel. Based upon the Zoning Board of Appeals' Decision dated September 16, 1994, in
Petitions No. 3128, 3129, 3130, and 3131, we believe that these aquatic recreational activities
are accessory to the existing motel use.
t993 Chalkstone Avenue, Providence, RI 02908 (401) 831-3131
ttl5 Caswell Lane, Plymouth, MA 02360 (508) 746-1818
Page 2
September 12, 1995
We therefore request a ruling as to whether the above described aquatic accessory uses
are allowed on the site under the Yarmouth Zoning By -Law.
Thank you for your anticipated courtesy in responding to this request for ruling.
Very truly yours,
Philip E. Magnuson
PE:jlc
CERTIFIED MAIL. RETURN RECEIPT REQUESTED NO, Z 348 644 000
FILED WITII TOWN CLERK:
PETITION NO:
HEARING DATE:
TOWN OF YARMOUTH
BOARD OF APPEALS
DECISION
SEEP 16 1994
3128, 3129, 3130, 3131
September 8, 1994
PETITIONER: Best Western Blue Water
Resort Hotel (#3128)
291 South Shore Dr.
South Yarmouth MA 02664
Green Harbor Village
182 Baxter Ave. (#3130)
West Yarmouth MA 02673
Red Jacket Beach Motor Inn
1 South Shore Dr. (#3129)
South Yarmouth MA 02664
Riviera Beach Resort
327 South Shore Dr. (#3131)
South Yarmouth MA 02664
PROPERTY: 327 South Shore Dr. South Yarmouth MA. Assessor's Map 22 Par-
cels T122, T125; 182 Baxter Ave., West Yarmouth MA. Assessor's Map 17 Par-
cel Sl; 1 South Shore Dr., South Yarmouth MA. Assessor's Map 14 Parcel Z1.
NM14BERS OF THE BOARD PRESENT AND VOTING: Leslie Campbell, Chairman, Fritz
Lindquist, John Richards, Richard Brenner, Joseph Conroy
It appearing that notice of the hearing has been given by sending notice to
the petitioners and all of those owners of property deemed to be affected
thereby, and to the public by posting notice of the hearing and published in
the Yarmouth Sun, the hearing was opened and held on the date stated above.
These four (4) petitioners involve virtually identical issues relating to
certain recreational activities conducted at these sites. As all four (4)
businesses are under common or overlapping ownership or control, the peti-
tioners requested and the Board agreed to conduct all four hearings simul-
taneously. All four petitioners are Motel/Hotel establishments, located
within the Residential (R-25) zone. Each is a pre-existing non -conforming
business. Each petition presents issues relating to the lawfulness of
existing "aquatic recreational activities" (so-called) being offered at the
establishments to the guests and to non -guests of the Motel/Hotel.
By letter of.July 8, 1994 (to the Red Jacket Inn), July 14, 1994 ( to the
Blue Waters), July 18, 1994 (to the Green Harbor Village and to the Riviera
Beach Resort), the Yarmouth Building Inspector instructed these petitioners
that their so called aquatic activities were in violation of the Zoning
Bylaws because they constitute Miscellaneous Amusements and Recreational
Services (N-11). The petitioners have appealed each of these rulings by the
Building Inspector, and each petitioner further requests the Board to
"define the term accessory use" relative to these businesses and activities.
The petitioners were presented to the Board by Mr. DeWitt Davenport. He
represented that these activities include: offering "Banana Boat" rides,
parasailing, catamaran rides, surf -sailing, and paddle boat rentals. Some
combination of these activities are offered at each motel. These activities
are run for the motel by sub -contractors who are properly trained and
staffed to insure safe operations. However, the petitioners maintain suf-
ficient supervision and ultimate control so as to be sure that these acti-
vities do not interfere with or detract from the principal motel uses. The
petitioners have marked out designated areas to which these activities are
restricted. Some of these, or similar activities have been offered by the
petitioners since 1968, according to Mr. Davenport. The majority of the
individuals (approximately 70-75%) using these activities are guests of the
motels. Non -guests are required to register with the resort or activity
operator and receive a "registered guest day -pass". Mr. Davenport repre-
sents that each facility has adequate perking, and that there have not been
reported any problems with traffic, parking, noise, crowds, or congestion,
nor have there been any accidents or dangerous situations.
Mr. Michael Frucci, Director of the Cape Cod Chamber of Commerce, and Mr.
Robert Du Bois, Director of the Yarmouth Chamber of Commerce, spoke in favor
of these petitions, each observing that these activities are a growing part
of the modern motel and resort industry for the area. Mr. Howard Wensley, a
neighbor, spoke in opposition to the petitions, citing concerns for safety
and the inappropriateness of such activities being offered to the general
public in these residential zones.
Members of the Board expressed some concern about these activities being
available to the general public by separate vendors. There was general
agreement that such activities,.if restricted to guests, would be an allowed
use, incidental to the principal motel use. It was noted that each of these
particular businesses characterizes itself and consistently endeavors to
operate as a "resort" facility, offering ancillary services to its guests
and, to a limited extent, to non -guests who wish to utilize such accessory
services. The petitioners operations, and self-imposed controls and
restrictions upon these activities, clearly keep them subordinate to the
motel use and principally available to motel customers, potential motel cus-
tomers, and guests of the registered motel customers. Some of the board
members expressed their belief that the activities, as represented, consti-
tute sufficiently related accessory uses, incidental to the principal motel
use, (although probably at the extreme limit of such a category). Other
members expressed a desire to allow these activities only for a trial
period, in order to better review and assess their impact upon the community
and the effectiveness of the petitioners' controls. After further delibera-
tions, a Motion was made by Mr. Richards, seconded by Mr. Conroy, to over-
turn the decision of the Building Inspector, and to find that these parti-
cular activities, conducted as represented by the petitioners, are permis-
sible accessory uses to the principal uses of these Motel/Resorts, includ-
ing their incidental use by registered day -guests; but to decline to other-
wise "define" the term accessory use, such a defining being beyond the
authority of this Board in this context. Mr. Richards, Mr. Conroy, Mr.
Campbell, and Mr. Brenner voted in favor of the Motion; while Mr. Lindquist
voted opposed to the Motion. The Motion is therefore passed and the Build-
ing Inspector's decisions appealed from are accordingly overturned.
Appeals from this decision shall be made pursuant to ss17 c40A and must be
filed within 20 days after the filing of this notice/decision with the Town
Clerk.
-'1
David S. Reid, Clerk
Board of Appeals
TOWN OF YARMOUTH
BOARD OF APPEALS
Filed with Town Clerk: SFP 1 8 ri
Petitioner: Myrna Rothman, et ali
'123 Wilfin Rd.
So. Yarmouth, Mass.
DECISION
Hearing Date: 8/14/80
Petition No.: 1691
The petitioner requested -a hearing of the Board of Appeals for the refusal of
Building Inspector to enforce the zoning laws. To wit: the rental of sailboats
in the residentially zoned area, being lots T125 & T133, Assessors map #22, Rivier
Beach Motel to 1) guests of Riviera Beach Motel 2) general public.
Members of Board of Appeals present:
Thomas George, Robert Sherman, Donald Henderson, Myer Singer, Herbert Renkai^:
It appearing that notice of said hearing has been given by sending notice
thereof to the petitioner and all those owners of property deemed by the Board
to be affected thereby and that public notice of such hearing having been given by
publication in the Cape Cod Times and Yarmouth Sun on 7/30/80 and 8/.6/80, the
hearing was opened and held on the date first above written.
The following appeared in favor of the petition:
Howard Spurr, Building.Inspector, Palmer Davenport, Paul McBride, Arthur
Hurley.
The following appeared in opposition:
Howard Wensley, Robert Block, Allan Rothman, George Yee, Anna Broughton,
Mrs. Rothman, Gerry Isaacson, Walter Mi:schke, Mrs. Wensley.
Reasons for decision:
The Board had an extensive hearing in this matter, listening to several persons
representing opposing viewpoints. Some Board members viewed the area prior to a
final decision.
The Board considered several items for example - accessary vs. non -accessory
in residential areas or in non-residential areas. The contiguous lot question
raised by the by-law, the rights of patrons whether guest or not, above or below th,
mean high water mark, past petitions of these owners or their predecessors, the
public vs. private aspect of'this motel and many other different angles of approach
Which we thoucht needed discussing, before a conciencious decision could be :wade.
Petition No. 1691
Page 2
The Board voted to affirm the actions of the Building Inspector by saying
that this is a legal accessory use to the motel if the activity .is conducted on a
lot upon which the motel by virtue of its previous special permits and variance ha
rights or on a lot on which this use is grandfathered.
The Board then affirmed the decision of the Building Inspector as to the
question of rental to the general public. In offering,the Board said "they may nc
rent to the general public without a Board of Appeals grant". The Board did not
believe that points 3 and 4 in Mr. Spurrs letter called for any action by the
Board.
Members of Board voting:
Donald Henderson, Robert.Sherman, Thomas George, Myer Singer, Herbert
Renkainen. All voted in favor of affirming the action or decision of the
Building Inspector for the above stated reasons, stating they may not rent to
the general public without Board of Appeals grant.
ROBERT W. SHERMAN
Clerk
TO:
FROM:
SUBJECT:
DATE:
BUILDING
TOWN O F-' -YA R M O U T H ELECTRICAL
GAS
1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664
Telephone (508) 398-2231 PLUMBING
SIGNS
BUILDING DEPARTMENT
Board of Appeals
Forrest E. White
Inspector of Buildings
Appeal #3217, AM 32 Parcel T119
August 11, 1995
Dear Board Members:
I have reviewed the Appeal of Silvio V. DiGiovanni for the
use of various aquatic recreational activities at 227 South
Shore Drive and have the following comments:
1). The request does not specify whether the rentals
are for the public or guests only.
2). Whereas the motel is a pre-existing non -conforming.
use, it is my opinion it could not be considered
an accessory use. Therefore, a variance would be
required as this parcel is in an R-25 zone and under
•202.5 (N-11). The use is listed as a NO.
3). If the use is granted to guests only, it would be
next to impossible to police who is using the acti-
vities. I know this from a previous experience
where a similar use was granted for guests only.
4). I believe there is a court case dealing with a simi-
lar use a few years ago in the Town of Chatham. I
do not have a copy of this case but it may be worth
looking into.
FEW: des.
Printed on Rt'/algid Paper
1146ROUTE28 SOUTHYARN10UTH MASSACHUSETTS02664-4451
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398.2365
Inspection Date:
Property Address:
BUILDING DEPARTMENT
NOTICE OF VIOLATION
Inspection Type: 0 2"
Name: Owner ❑
D / B / A• , 0 �� Telephone:
Mailing Address:
City / Town: _
6
State:
Tenant ❑
Zip Code:
6f /er
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
An inspection of the above captioned property was conducted by the undersigned,
You are hereby ordered to abate or correct said violations within days.
Failure to do so may result in .criminal/civil complaints being filed against you, which
may be subject to fines as prescribed •bypertinent laws and regulations, or may delay
the issuance of your license. You are also requiredlo contact the Building Department for
a re-inspec n by the time noted above.
Signed:ir. .�...�'we
Inspector
Title
N(C.-
ON
4<
Copy. Received By:. �s
Original - Owner
Cppy - Licensing Authority Pink Copy - Bldg. Dept.
0
o
D MATTACMrrS
t2
BUILDING
' Y°=A- M O U T H ELECIRI�I
TOWN O F
1146ROUTE28 SOUTHYARAfOUTH AIASSACHUSETTS02664-1451
Il Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
NOTICE OF VIOLATION
GAS
PLUMBING
SIGNS
P1 _
Z? Inspection Date: �G�vi Inspection Type:
-�01
Property Address: b
Name: Owner ❑ Tenant ❑
D / B / A: i1.Lr,/ y/ Telephone:
Mailing Address:
City / Town: State: Zip Code:
+i(c� An inspection of the above captioned property was conducted by the undersigned,
dJ t which the following VIOLATIONS were observed: ' a S
., _ ,.. _. _ _ i. .n „c
You are hereby ordered to abate or correct said violations within days.
Failure to do so may result in criminal/civil complaints being filed against you, which
may be subject to fines as prescribed by pertinent laws and regulations, or may delay
the issuance of your license. You are also required to contact the Building Department for
a re-inspecti by the time noted above.
Signed:
Inspector • ��` Title
4,vtl
- -- Copy Rece%ed By:
Original -
Licensing Authority Pink Copy - Bldg. Dept.
TOWN OF YA R M O U T H BUILDING
GAS
1146 ROUTE 28 sOUT11 YARMOUTII MASSACHUSETTS 02664-4451 PLUMBING
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-0836
SIGNS
BUILDING DEPARTMENT
NOTICE OF VIOLATION
Inspection Date: y % Inspection Type: C_T_
Property Address: 7 7 7 ,. I i- i/
Name: = , - -{ �' Nl Owner 0_�' Tenant ❑
D / B / A: , Ivy'. i rv� -,n Telephone: 1 i Q "7 `-
Mailing Address: ' '- y % 7y
.
City / Town: - State: r •i Zip Code::
An inspection of the above captioned property was conducted by the undersigned, during which the
following VIOLATIONS were observed:
1 ✓ / f .ter.__
v
l �Lzl< 74
,- << e f 5
L c xl—y .
1 Cam, C. N
Jim-•�C � �" � i / .� � .
You are hereby ordered to abate or correct said viol ations'within days.
Failure to do so may result in criminal/civil complaints being filed again t you, which maybe subject
to fines as prescribed by pertinent laws and regulations, or may delay the issuance of your license.
You are also required to n act the ui ig e a iment for a re -inspection by the time noted
above.
Signed: 17
(/y //1
.Inspector f Jitle
Copy Received By:
Original - OwnerrFenant
Yellow Copy - Licensing Authority Pink Copy - Bldg. Dept.
a
m
m
IL
m
U
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m
O
Z
i
0
O
4
Y
owl, o� URFIOUTx
BUILDING
/
l�-02 -`�� �,/ //�/4 -
PERMIT
I
F
1>
1�
r
DATE -November
21. 2001
PERMIT NO. 8-02-464
APPLICANT— Assured Property
Services, Inc.
ADDRESS 350 :+ncock Streets
Quincy *12 CS077813
(NO.) (STREET)
(CONTR'S LICENSE)
PERMIT TO repairs
I—) STORY
NUMBER OF
DWELLING UNITS
(TYPE OF IMPROVEMENT)
NO.
(PROPOSED USE(
'
AT (LOCATION)277 South Shore Drive, SY 02664 o STRNICT R 40
IND.) (STREET)
BETWEEN AND
(CROSS STREET) (CROSS STREET)
SUBDIVISION 26/127 LOT_
BUILDING IS TO BE FT. WIDE BY FT. LONG BY
TO TYPE
REMARKS
USE GROUP
LOT
BLOCK S12E
FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
BASEMENT WALLS OR FOUNDATION
(TYPE)
AREA OR MIT
(CUBIC/SQUARE FEET)
VOLUME ESTIMATEDCOST $-44T000T00—FEE $ fiO 00
�.
OWNER -Surf and Snnd Mntel
ADDRE55277 South Shorn Drive, SY 02664 BYILDING DEPT./
A ��,
INSPECTION RECORD
t
DATE I NOTE PROGRESS - CORRECTIONS AND REMARKS I INSPECTOR
cOlTree Use Only +'
Permit #��7
Fee S
Permit ue•�� months from'.
issue date.
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261 , 1
CONSTRUCTION ADDRESS:
ASSESSOR'S INFORMATION:
(Map: Parcel: 02
OWNER: �,,r�IV-sGwd�-e� .o�%C�s.SVtoJ�G�J�. �i�%-ys�/—a63!
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: y6e L)re j 6 Roe Sery�ees.1,t C 35a e.,�eo�k S . (�.,t�,u„ N1 � 11 7'773'Y4
NAME MAILING ADDRESS T
❑ Residential )�Lmercial Est u
Cost of Construction S - U;4 . 190 0
Home Improvement Contractor I.io. # J 3l 7 / g . Construction Supervisor 11c. #
Worktu m's Compensation Insurance: (check one)
Cl I am the homeowner ❑ I am the l
soleproprietork have Worker's Compensation Instrance
Insurance Company Name: 7 v r I &, \ _Worker's Comp Policy# WC 00 6467310
PERFORMED D
❑ Tent(Fire Retardant Certificate attached) D
Duration (�I, NOV 21 2001
❑Siding: #ofsquares t,�
vv❑ Replacement windows: # NOV V 1 Z U U, ❑ Replacement doors:
IyRe•root #of Squares-O� �Cr)
1 O Stripping o "gles' y-(j goingmer— laren oLastingroof
*The debris will be disposed of at:
Location of Facility
I declare under penalties of perjury that t!�cstatcmcnts herein contahoedare true and correct to the best of my knowledge mod belief: I understand that any false answcr(s)
will be just cause for de ' oca ' �ficc �ntiou�und,!,L_rl G I Ch 268, Section 1.
Applicant's Sig e• rirDate: o2t�0{
Owners Signature
Approved By: 142 /l��i//�+. Dar:
—''u ding Official (or a 'ghee)
Zoning District: t- U
Historical District: ❑ Yes' No Flood Plain ZonelVYes ' ❑ No
Water Resource ProtQet n District: Within 100 & of W U .
❑ Yes [� No ❑ Yes No
3/01
Proposal Submitted To Homeowner `
se— Work To Be Performed At
Na�S — }_ y_\' 450.y\
Street
Street SXM (-.740-kp�city
city state )N �'
state
6 I _ _ 3'
n
Date 4-10 Telephone � / ' 469 07 7
Dais of Plans
Complete Descriptions of Work to be Performed:
_ �i may`^'• �.7 • � t Y ?: _...
Y t� t
r,...; 1
hmtav'14,,rpit Cv, v�
. o
V
Date work will start A /" Date work will be completed is 6 0
All material Is guaranteed to be as specirad. All work to be completed In a workmanlike many er according Io standard practices. Arty elteradon or deviation from the above specifications
must be made in writing on an Add-orvkAodirication of contract forth and may become an extra cheige over and above the amount stated herein. This agreement is contingent upon delays
beyond our control. Owngrs to carry fire, tornado end otter necessary Insurance. Our workers are fully cov"d by Workmen's compensation Insurance, Homeowner agrees to pay for
all work as set forth belpw. If the horneowner defaults, homeowner agrees to pay all costs of collection, Including reasogabie attorneys fees, in addition to other damages incurred by
contractor. A 1 1r2% per month service charge will be assessed for all payments not made within 10 days of the due date. $50.00 fee foryeturned check charge.
hereby to lur%fish material and tabor—complet In a`cccordance with the above specifications, for the sum of:
=wprgpose
�i rrn-a dollars Said amount shall be paid as follows:
Note:.This proposal may be withdrawn by us if not accepted within A) days.
`YOU, THE BUYER, MAY CAN CELTHIS TRANSACTION ATANY TIME PRIOR TO MID NIGHTOFTHETHIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION
OF THIS. RIGHT. (SATURDAY IS A LEGAL BUSINESS DAY IN',CONNECTICUT.) THIS SALE IS SUBJECT TO THE
PROVISIONS OF THE HOME SOLICITATION SALES ACT AND THE HOME IMPQOVEMENT ACT. THIS INSTRUMENT IS
NOT NEGOTIABLE. ,�p�
Work be begun has ��/ UW
will not until your right to cancel expired and you have paid a deposit of r
"(S(J
dollars (V S C500 i ), unless this agreement provides otheflN a. `—
� � 1stI�CGP � l��yict3
Signature of Contractor or authorized representative:
• (I/We) have read the terms stated herein, the grave been explained to (melus), and (I/We) find them to be satisfac-
tory and hereby accept them. l
Signature of Homeowner(s)::,1_19 -�
tit
1
07 '0awmwuv6a1d
t I BOARD OF BUILDING REGULATIONS
t License' SCONSTRUCTION SUPERVISOR I
7.4 Number..CS 077813
Blrthdate: 10/10/1957 j
Expires:1011.012004 V. rw 77813
Restricted To; 00
LEONARD BLANEY
I { 69 LEONARD ST #2 �� .�✓' — `' i
i RAYNHAM, MA 02767 Adropustrator
Le
Board of Building Regulations and Standards
HOME WROVEMENT CONTRACTOR
1
Registration:..131748
'i
Expiratioa: 09/08l =
Type:
t ASSURED PROPERTY SERVICES
LEONARD BLANEY_'J
350 HANCOCK STREET �+
N QUINCY. MA 02171 ;-,-•_-•--
/o � 360 -.c.�efrarinunl a�Jire S'irvictd Pemtit No.
BOARD OF FIRE PREkvIvIt'VENTION REGULATIONS LRevr.�an`y Fee Clteckcd
111991
fletve blank)
APPLICATION FOR PERMIT TO -PERFORM ELECTRICAL WORK
All work to be performed in acconlancc with the Massachusetts Elatrical Code (MCC), 527 ChlR 12.00
(PLEASE• YIUNTININK OR TYPEALL ItV!'O M:ITION) Date: — O 1
City or 'Town or. Q /\6"til TO Ilse Inspector of Wres:
By this application the undetsig d elves noticf of hid or her intenuou to performthe electrical work desrrihed below.
Location (Street S t\umber)''
�
Oiv ticr or Tcnaut •�^—�—`
Owner's AddressAl —
Telephone No.396- 3 700
Is this permit In conjunetluu will, a building permit? Yes ❑ No Q1 (Cltecl: Appropriate Box)
Purpose of Huftding ;-�?07re
Utility Authorizattuu No.
Existing Service Amps / Yolk
Ncn Sen•icc Anips / Fulls
Number of Fcedcrs and Ampacity
Localluht and Nature of Proposed Electrical Work.
oll'c a r✓�/ � under 1?9o1,n .10 r
Overhead ❑ Undgrd ❑
Overhead ❑ * Undgrd ❑
or ocmwe.T
No. of Aletcrs
No. of Meters
No. of Recessed Fixtures
-- •••-••-^"••••-•.•••^••••cMUM
No. of CciL-Susp. (Paddle) Faus
May CC ulallvort or 11:0 nlsocrlor of m tb•Cs
No. o Otal
Transforncrs KVA
No, of Lighting Outlets
No. of llut Tubs
Generators XVA I
No. of LightingFixtures
Swimming Pool Above ❑ u-
rnd• rnd.
o. o huergencLighting —
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of 0hes
No. of Switches
No. of Gas Burners
o. oI let000rtion and
Initiating Deices
cv -c
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerttng Devices I
00
No. of �Yaste DisposersTotals:
cat rump
Number
ons
o- o - Ontahie
Detection/Alertine Devices
o
T3" e I
No. of Dishivashcrs
Spacc/Area Heating InV
Local ❑Alumcip2l ❑
Connection
iter
No. ofDrycrs
7157 of ester
Heaters kAN
HcattngAppliances XNY
o. a h o. of
Shms Ball:uts
SccuritySyStems:
No. of Devices Or E uivalentt
Data Wiring:
No. of Devices or E uivalcnt
No. H%-drutnassage Bathtubs
No. of Alotors Total IIP
ecommua cations rung:
No. of Devicrs or Eauivalent
OTHER:
Altadi additional detail ifderurd, oras required by the 111sp.ctor of Ihres.
INSURANCE COVEILICE: Unless waived by the owner. no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. Iltc
undersigned certifies that such coverage is in force, and has exhibited proof ofsame to the permit issuing office.
CHECK ONE: INSURANCE eIIOND ❑ OTHER ❑ (Specify. e., e/ t:Jakli
` (Ecpmrauon Date)
p E•stitrated Value of EIectrical Work:' (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pants and penalties ojperjnrr, that the in/onnariolt all this application is true and eontplc•1G
FIMINAttME: v, rd t- 121erry LiCo. NO.:357Y5':6�
Lieensce: Signature L1C. NO.:
(Ifapplicable,enter••cum t"inthe licensenumberlfns) Bus.0 No: 8
Address: An. RnX a93 V4I`tnout/,pprt Ma o�L%S'~"' AlLTe1.No.•
OWNER'S INSURANCE W. Ell.: 1 anh aware that the Licensee does not (rave the liability insurance coverage normally '
required by lave•. By tnv sicnaturc below, I hereby waive this requirement. I am Ute (check onc) ❑ ovvrter ❑ ou•tur's as ent.
Omvncr/A;cia
Sisuatur• 'I'cicphouc NO. PiiR/1lIT FEE: S
.The Commonwealth. ofi1�¢tsac�srtsertr
DcFar=c"kvflndres-idAc=&k r
&AT=.I n --- ,! - %ray
• 64UWash�, onsae~
Bosun, Mast. OZIII
wGecer='
r
1 a hel:teowst� per'asaistz all woof mysciE
1 I art a sate prm;m=r and !save 0o One Wcdcb � is
At?•idavit
calovec7evidin3 W�.�,
_ • • r, .. t �$lOyCs warm OII dzis f eb.
Cl 1 ass a sale e& wF4iamer4l e0as= 2=r. or hameaw rter (e�s•tle arse sad have sa-^+ a ^�ssz^..rsrs tiz'� below who csv
the following w•ati�t Cott po�cs:
rapture to taeare even as regatrtV racer �aeaae 3•� etbtGL lT tan Ida to tae impealaea of eremtnal an* �esrt• imarinamenc as w di as eieil penalde is dta farm *to ST— WORK ORDER and a dae notmomi p nada cs o[s Qea up to SL_xcax° aed/ar
eon of chic atateseac ma. be ror�ardad m me Olriee Kiebdptdam otme OtA rat �staac me I eaderstsad :st a
e�erats.eriQesdew. ,
1u irar�r a:fjej setderthe paiecs and pe�rsltta
arriaal use ottt+
P—
that rha injorrttatiotr prvWded &[Sore Fr trma and GOrt•--
m2= _ yam-/7- ot�o
as [tat ..nte in tMa arts to Oe eamplated Op ert. or met aRieial
�^itEE O �a�iJS
ern Mr.town: —
T' pet•miulic:ttta a r!!luildin� Oepatsmrat
_ eaeer :cimmediate raMme is required Qt.(esvaittt board
CSeleetmen's Orrice:
:anger ne�nn: �� •' 11 �/Q
=C t (]Hearth m 0evertmt •.
annw.e. C..-O—
.6 • •Y1.. -f,A •', • 1 ..... ..1 i..1. fn.iii '•1 ill-- n I- -.
t •pF • q� � • Btn ]ING
TOWN OF Y A R M O U T H E17rXUCAL
0 H 0
(J� 1146 ROUTE 28 SOUTH YARDIOUTH AtASSACHUSETTS02664-4451
MAT CHEM PLA:IL ING
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
NOTICE OF VIOLATION
Inspection Date: 2 ;P ;?&p J Inspection Type: —
Property Address: -2% 7 A.
Name: 33 Owner ❑ Tenant ❑
D / B / A: f 4 /'7 Telephone:
Mailing Address:
City / Town: State: Zip Code:
An inspection of the above captioned property was conducted by the undersignd,
during which the following VIOLATIONS were observed:
a�-
c
�. ...>
J-
o �i dip
y
400,01,
Your are Hereby ordered to abate or correct said violations within �'S days.
Failure:to do so may result in criminal/civil complaints being filed against you, which
may be subject to fines as prescribed by pertinent laws and regulations, or may -delay
the issuance of your license. You are also required d'contact the Building Departmentfor
a re-inspec io 'by the time no ed above. nA....�
Signed:
Inspector Title
Copy Received By:
Original - Owner/Tena Yehos ,C py Licensing Authority Pink Copy - Bldg. Dept.
re
*' %�i{ - .
'� TO W N O Fj LBUILDINAY R M O U T1G
1146ROUTE28 SOUTHYARMOUTH NIASSACHUSETTS02664.4451
SIATTACHS[S
t Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365 irPLUriBLVC
SIGNS
(70� o BUILDING DEPARTMENT
b t 1 NOTICE OF YI.OLATION
? Inspection Date: �vj Inspection Type:
! Property Address: ? % ✓/
Name: Owner ❑ Tenant ❑
i D / B / A:z Y:f�z Telephone:
1�: • -
Mailing Address:
City / Town: State: Zip Code: '
An inspection of the above captioned property was conducted by the undersigned,
dgring which the following VIOLATIONS were observed:
5Ar
—=--MMWd A
Id
You are hereby ordered to abate or correct. said violations within days.
Failure to do so may result in criminal/civil complaints being filed against you, which
may be subject to fines as prescribed by pertinent laws and regulations, or may delay
the issuance of your license. You are also required to contact the Building Department for
a re-inspecti by the time noted /aJbove.
I �`
Signed: Z.
Inspector Title
Copy Rece ved By:
Original - O%merfrena Y low opy - Licensing Authority Pink Copy - Bldg. Dept,
ALL OCEANFRONT UNITS
UFA
BL7LDING
T O W N
OF YA R M
OUTH
1146 ROUTE 28 SOLTH YARMOUTH MASSACHUSETTS 02664
0 FFr \ I Tcicphonc (508) 398-2231
" W 2419% BUILDING DEPARTMENT
PLICATION TO ERECT AND HAINTAlN SIGN
ELECTRICAL
GAS
PLU.
RING
MAP �L�)_ LOT %//9 ' DATE Z�j' 19
TO THE SIGN.INSPECTOR: UNDER SECTION 303 OF THE YARMOUTH BY -LABS, THE {UNDERSIGNED
HEREBY APPLIES FOR A SIGN PERMIT ACCORDING TO THE FOLLOWING'INFORMATION:
S�v r • �TEL•
BUSINESS NAME . S '� e\
LOCATION/ADDRESS � T) Sk'i3'� N 1 .
-r
ZONING DISTRICT L.B. G.B. IND. RES. /v-' HIST..DIST. c r1
BUSINESS OWNERS .NAME/ADDRESS S (IV �C) U �� �c 1yy) IJ L ~TEL:
OWNER OF RECORD OF BUILDING s (� V V . l� b(Dlau (N,-)ARIESS
SIGN BUILDERTtn 1ac:u 1 S ADDRESS C63 VC' -A w S V TYPE OF CONSTRUCTION MATERIAL(S)Z��Y-\S�LC 'LIGHTING-,�TYPE &Ll.-
FREE STANDING" ' ATTACHED TEMPORARY PERtIANENT411�=
DIAGRAM OF LOT AND SIGN WITH DIMENSIONS AND SET -BACKS FROM -PROPERTY LINE. SHOWN
LETTERING AND ADVERTISING ON SIGN. FOR ATTACHED SIGNS SHOW LOCATION ON FACE OF
BUILDING AND RUNNING FOOTAGE OF PORTION OF FRONTAGE OCCUPIED BY BUSINESS.
v � SQr-r
S\cLv\ C.` YOAC.k
� w
I HEREBY AGREE TO CONFORM TO THE ZONING BY-LAWS, SECTION 303 OF THE TOWN OF YARMOUTH
REGARDING THE ABOVE SIGN CONSTRUCTION. I FURTHER AGREE THAT THIS SIGN WILL NOT BE
ALTERED,:ADDED TO, OR CHANGED IN ANY WAY UNTIL A NEW PERMIT HAS BEEN GRANTED. THE
NUMBER OF THIS -PERMIT WILL BE AFFIXED TO THE SIGN IN NO LESS THAN 3/4" NUMBERS.
ALL PERMITS SUBJECT TO APPROVAL OF THE SIGN INSPECT/OAR. o 0 o�a2Ito
NAME /' �✓Ti� ,
APPROVAL BY 4� / /
DATE ���.-'�' �;�� FEE �7 _ NUMBER
PERMIT 87 e� 2/12/99
2/12/99
LOT T-119
DiGiovanni, Silvio (Surf & Sand)
277 So. Shore Drive
South Yarmouth, MA 02664
Replace railing in front of bui ding.
a/y/y ,000.00
SHEET 22
TOWN OF YARMOUTH
Application for a Permit to Build No. g%
UPON FINAL APPROVAL frV 4 MAP �Z LOT �/ / 9
FEE MUST ACCOMPANY THIS APPLICATION. DATE 1
The undersigned hereby applies for a permit to build
ac ording to the following specifications §iW4,L�L
1. Name of property owner �6ia (*AAI Tel.6f7-%'I -0774
Address 977 - ,t hrX. A•
2. ameofArchitect (1 any rr'' Tel,
Name of builder ddress W
4. License No. (271 Tel. 24—W70
5. Name of Mason Address
6. icense No. Tel.
Construction address ail Sa.ee. Q�wtc
8. Date of subdivision Approval
9. Private dwelling ❑ Estimated Cost
10. Multifamily ❑ POO
11. Commercial ❑ B
12.Other ❑ D,7 2
13. No. of stories G o
14. Foundation = Full ❑ Half ❑ Crawl ❑ Slab ❑
-- 15. Materials — Wood ❑ Cement ❑ Other ❑
plain zone
16. Type of heat — Oil ❑ Gas ❑ Electric ❑ Other ❑
17. Garage —1 ❑ 2 ❑
18. Swimming pool - Size
19. Storage shed — Size
20. Stove — Wood ❑ Coal ❑
21. Size of lot: No. of feet front
22. Size of building. No. of feet front
23. Distance from nearest building: Front
24. Distance back from line or street
25. H.I.C.R. No.
LOT RELEASED BY
PLANNING BOARD
Date
Sig
No. of feet rear
zone
DO NOT WRITE IN THIS SPACE
I Tvpe of room
/1)J7O-C
No. of feet side
Ft. side
From rear lot line
Dining Rm.
Living Rm.
Bed Rm.
Bath
Deck
Closed porch
Family Rm.
Sun room
Shed
Alterations
_ No. of feet deep _
No. of feet rear _
Ft. side Rear
Side line
20
BUILDING PERMIT APPLICATION SIGN OFF
APPLICANT.N, BUILDING PERMIT U:
ADDRESS: TELE. NO.:� DATE FILED:
BLDG. SITE LOCATION: S ^ MAP#: `,} �" LOT#:
THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD,
ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER-
MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD
PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH
THE FOLLOWING DEPARTMENTS:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY.
ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE.
CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E.: IF LOT(S) BORDER ANY
TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH
LAND, ETC.
HEALTH DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E.: REQUIRE-
MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES.
FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL.
SAFETY, PROPERTY PROTECTION, I.E., SMOKE DETECTORS, SPRINKLER SYSTEMS,
ETC.
THE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR
ISSUING THE REQUIRED BUILDING PERMIT:
REVIEWED BY:
1. WATER DEPARTMENT DATE: N/A:
2. ENGINEERING DEPARTMENT: DATE: N/A:
3. CONSERVATION: DATE: N/A:
4. HEALTH DEPARTMENT DATE: N/A:
INDUSTRIAL AND/OR COMMERCIAL PERMITS
5.
WIRING INSPECTOR:
DATE:
N/A:
6.
PLUMBING INSPECTOR:
DATE:
N/A:
7.
FIRE DEPARTMENT:
DATE:
N/A:
PLEASE NOTE
ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE
DISPOSAL SITE MOST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING
PERMIT.
COMMENTS:
BLM 89
0 1 am a homeowner performing all work m)self.
I am a sole proprietor and ha%e no one working in any capacity
0 lam an cmplo%er pro%iding workers' compensation for my employees working on this job.
ida fe...
insurance co policy t!
0 1 am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below who ha%e
the follow in_ %%orkers. compensation polices:
Failure to secure coverage as required under Section 25A orMGL 152 can lead to the imposition of criminal penalties of A One aP to SI.S00A0 and/or
one years' lmprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SID0.00 ■ day against me. I understand that a
copy of this sulement may be forwarded to the 09;ce of Investigations of ebe DIA for coverage verifiadoa.
I do hereby ijy ui the�ns
Print
that the information provided above Is true and correct
Date g1fl9
Phone # 10— / O
ofcial use only do not write In this area to be completed by city or town official
city or town: YARMOIIT11 _ permitAicense 0 nBuilding Department
(3ucensing Board
O check if Immediate response is required 261 OScleetmen's Otfice
contact person:
❑Health Department
phone#;_ (508) 398-2231 eat. rnOtbcr
j,"d 3,q5 PJA1
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
entplo%ees. As quoted from the "law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An enrplor•er is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the foretaoine engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the
o%%ner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another %%ho employs persons to do maintenance , construction or repair work on such dwelling house
or on the aruunds or building_ appurtenant thereto shall not because of such employment be deemed to be an employer.
NIGL chapter I:'_ section :: also states that even state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally. neither the commomyealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter hay e
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying, company names. address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affidavit should be returned to the city or town that the application for the permit or license is being requested.
not the Department of Industrial accidents. Should you have any questions regarding the "law" or if you are required
to obtain a %%orkers' compensation policy, please call the Department'at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affdavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
MCC of ItiveSU180112
600 Washington Street
Boston, Ma. 02111
fax 4: (617) 727-7749
phone #: (617) 7274900 ext. 406, 409 or 375
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT:,
JOB LOCATION
OWNER OF PROPERTY:
CONSTRUCTION SUPERVISOR:
ADDRESS:
I,i D �LJI.Gi a (�Anh
091
r/w Mj41, IQ
VILLAGE
NO. PHONE NO.
LICENSED DESIGNEE:
(IF OTHER.THAN SUPERVISOR) NAME LICENSE NO.
2.15 RESPONSIBILITY OF EACH LICENSE HOLDER:
2.15,1 THE LICENSE HOLDER SHALL. BE FULLY AND COMPLETELY RESPONSIBLE FOR ALL WORK FOR WHICH HE
IS SUPERVISING. HE.SHALL BE RESPONSIBLE FOR SEEING THAT ALL WORK IS DONE PURSUANT TO THE STATE
BUILDING CODE AND THE DRAWINGS AS APPROVED BY THE BUILDING OFFICIAL
2.15.2 THE LICENSE HOLDER SHALL BE RESPONSIBLE TO SUPERVISE THE CONSTRUCTION, RECONSTRUCTION,
ALTERATION, REPAIR, RLMOVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING
AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE
COMMONWEALTH,. EVEN THOUGH HE, THE LICENSE HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB—
CONTRACTOR'OR CONTRACTOR TO THE PERMIT HOLDER.
2.15.3 THE LICENSE HOLDER SHALL IMMEDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE
DISCOVERY OF ANY VIOLATIONS WHICH ARE COVERED BY THE BUILDING PERMIT.
2.15.4 ANY LICENSEE WHO SHALL WILLFULLY VIOLATE SUBSECTIONS 2.15.1, 2.15.2 OR 2.15.3 OR ANY
OTHER SECTION OF THESE RULES AND REGLZATIONS AND ANY PROCEDURES, AS AMENDED, SHALL BE SUBJECT
TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD.
2.16. ALL BUILDING PERMIT APPLICATION'S SHALL CONTAIN THE NAME, SIGNATURE AND LICENSE NUMBER OF
THE CONSTRUCTION SUPERVISOR.WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON-
STRUCTION, ALTERATION, REPAIR, REMOVAL OF DEMOLITION AS REGULATED BY SECTION 109.1.1 OF THE
CODE AND THESE RULES AND REGLUTIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISING
SAID PERSONS, THE WORK SHALL IMMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED
ON THE RECORDS OF THE BUILDING DEPARTMENT.
I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS FOR LICENSING CON-
STRUCTION SUPERVISORS IN ACCORDANCE AITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTIL:,
THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING
OFFICIAL.
INSURANCE COVERAGE:
1 have a curr nt liability insurance policy or its substantial equivalent which meets the requirements of MGLCh.152
Yes No ❑
If you have checked ves, please indicate the type c average by checking the ap:rcpriate bex.
A liability Insurance pc:icy ❑ O:her type of :�demnity ❑ t3ond ❑
OWNER'S INSURANCE WAIVER: I a aware that the ucensee doei not have the Insurance coverage. required =y
Chapter 152 of the Mass: General is , ano t"at my signature on t ::s permit ccplication wanes this requirement
Check one:
OwnerO Agent ❑
SIGNATUi'W"_j<S%f{/f (_ I-4'VV 1 BUILDING OFFICIAL APPROVAL:
• - The Commonwealth of Massachusetts �_po:nre c..ntr
O A resit SO.
Department of Public Safety
occupant' a Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 (leave slant)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AD work to be performed In accordance with the Mascachusetss Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR y TYP
,E
/ ALL INFORMATION) Date ,2 // /UU
City or Town of )T/If
C) ✓%`/�jr To,tha Inspector of Wires:
The undersigned applies for a permit to perform *the electrical work descrM4.4 belgrA-\ n ^ 1
Location (Street 6
Owner or
Owner's Address " .6d
Is this permit in conjunction with
/ta building permit: Yes �— No ftpy.
Purpose of Build ig � � 4✓L Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service. I(3ZAmps { " V Jf/,4,0, Volts Overhead 0- Undgrd ❑ No. of Meters_
Number of Feeders and Ampacity /
Location and Nature of Proposed Electrical Work 7V5' ✓�P��2jtit2 y S%�'!//C/E
7-2 AV ! G P
No. of Lighting Outlets
No. of Hot Iubs
No. of TransformersTota
KVAl
No. of Lighting Fixtures
B 8
Above In-
Swimming Pool rnd. ❑ grnd. ❑
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency LightingBattery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
NO. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local ❑ Municipal ❑ Other
Connection
No. of Ranges
No. of Air Cond. Ttons
No. of Disposals
No. of Punts Total To
Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters lu
No, of o. o
Si ns Ballasts
LOW Voltage
Wring
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liabilit Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES ❑ NO L] I have submitted valid proof of same to this office. YES ❑ NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE % BOND ❑ OTHER ❑ (Please Specify) Ov
iration ate
Estimated Value o Ele trical Work S 3�0 . Gb
Work to Start Inspection Date Requested: RoughA113,1491D,
Final
Signed under the p nalties of perjury:
FIRM
. NO.
. NO.a?6tlo /0
Address.Z X: F)K� oeU w. yAepp '47� . "* -. ". .1t—., 1 . I I
Alt. Tel. No.
OWNER'S INSURANCE -WAIVER: I am aware that the Licensee does not have the insurance coverage or is sub-
stantial equivalent as required by Massachusetts General wsa�at my signature on this permit
application waives this requirement. Owner Agent (Please check one) .
Telephone No. PERMIT FEE S
Signature of Owner or Agent
lot Only
- The Commonwealth of Massachusetts O:l lee �-0e
f Dcporfinenf of Public Saay
✓ __ = occupancy L Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1=0 3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed In accordance with the Macsachusetss Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORISA_TION) Date /�y /UD
City or Town of YwiO VTy To,the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work descrpwd belgrAX n ^ j
Location (Street 6
Owner or
Owner's Address " ✓
Is this permit in conjunction with a building permit: Yes Is- No y )
Purpose of Building Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Haters
New Service. Volts Overhead �- Undgrd ❑ No. of Meters_
Number of Feeders and Ampacity, /
Location and Nature of Proposed Electrical Work
No, of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimming Pool Above In-
grnd. ❑ grnd. ❑
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local Municipal Connection []Other
❑No.
No. of Ranges
tal
No. of Air Cond. Ttons
No. of Disposals
No. of H�ts TTons ToKW
No. of Dishwashers
Space/Area Heating KW
of Dryers
Heating Devices KW
No. of Water Heaters KW
No, of No. of
Si ns Ballasts
Low Voltage
Wirin
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES ❑ NO [] I have submitted valid proof of same to this office. YES ❑ NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE BOND ❑ OTHER ❑ (Please Specify) Ov
(Exeiration ate
Estimated Values o� Ele trical Work S. V0
Work to Start/ /� Inspection Date Requested& Rough ID Final
Signed under the p nalties of perjury:
FIRM NAME
NO.
NO. O /O
it. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S
Signature of Owner or Agent
^� r. .r .� ...�...�.y ov'•..- ... '.��. r+r..--.. ... a'P r^.-. :W'rv-w,.� ...-w..'.r. ,.-v..i...x. �r.. •.� v .. .`.�_� .. ...
0'd APPLICATION FOR PERMIT TO INSTALL AND REQUEST
IN--\ FOR ELECTRICAL SERVICE
E•DD_�D
� Inspector of w�it%s ` Wiring Permit # COM/Electric #
Town of `!� A k" 0 rH Massachusetts Building Permit # Date
Customer: "�' tollaz on (Street #)
Lot # in the village of S o v t'/ /7 ' utility po n.ytuber or underground numb r Z
Customer's billing address �J % % - '� • rAQ r ..iti / I b J9�1
Temporary K ' New installation x Change of service Starting Date
y
Job description /NSTA["I- 1-PM/0UF 0404' S/ci('✓/CC TO (70/kJS77;?wGj
'S/NGc A� /=Awt le v AFT" nic.F
Service entrance voltage U yV Amperage /c'U
Phase }"
Wire size (cu. or,al.) 2 Conductor per phase
Number of meters / Water heater _
Off peak: Yes —
No
<
Estimated load: Electric heat �' kw, lig�Is
kw, Range "—" dryer Motors, H.P.`8 Phase
r
Ready for first inspectio / / U
Ready
for final inspection
Electrical Con actor �` A PN f "S
Lic, #
.� G G/
o Telephone # %�G a i�6
Address FA 5- reooK Rd
tA� .
`i,�.c
^-I o L,,7W 1,
Additional Remarks:
Do Not Write Below This Line
ELECTRICeLL WIRING INSPECTION CERTIFICATE
INSPECTIONS ^ n NSPECTOR OF WIRES q �D�T�
Temporary Service
Roughing in
Service and Meter
Off Peak Meter
Final Approval
Disapproved'
'For the following reasons
FEE CHARGE
CERTIFICATE OF -INSPECT ION
To the COMMONWEALTH ELECTRIC COMPANY. The installation described above has been comp) t apd s is da een inspected and
approval granted for connection to your service. r [S Q��
Inspector of Wires
r r
WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit Good For One Year From Date Of Issue CA 46-1
White — COM/Electric Green — Inspector Canary — Town Receipt Pink — Inspector's Copy Goldenrod — Electrical Contractor
to COM/Electric
TOWN
BUILDING
OF YA R M O U T H ELECTRICAL
1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664'
lclephone (508) 398-2231
BUILDING DEPARTMENT
Atty. Philip E. Magnuson
255 Main Street
Hyannis, MA 02601
Re: Aquatic Activities
,277 South Shore Drive
Dear Phil:
GAS
PLUMBING
SIGNS
October 17, 1995
As you know, I have spoken with Mr. D. Giovanni about the
use of aquatic activities at the Surf 'N Sand Motel. It was,
and still is, my understanding that an accessory use cannot be
added to a pre-existing, non -conforming use without Board of
Appeals approval.
In the Davenport decision you referred to, the problem was
that the activities were being rented to the public. A Board
of Appeals decision back in 1980 agreed that these activities
were an accessory use at that time and "they may not rent to
the general public without a Board of Appeals grant".
Non -guests who register with Surf IN Sand to receive a "reg-
istered Guest Pass" enabling them to rent the equipment, to me
is the same as renting to the public.
My opinion is that a special permit is required from the
Board of Appeals in order to offer these aquatic activities to
guests and so-called day guests to the Motel.
Enclosed please find copy of 1980 decision.
Very truly yours,
Forrest E. White
Inspector of Buildings
FEW: des
Enc. 1
xc: Board of Appeals
�p
Printe(l on Perycleo Pwer
111
W
W
IX
l.o"nwaa& o` Mamac"th ; Qlricial Use Only
. UaParinun� o��in Jatvicu Permit No. Z — 7 t�
' Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS ev. 1/07j cave bleak
APPLICATION FOR"PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 04110. 527/CMR/i 7 nn
(PLEASE PRINT IN INK OR TYP9 ALL INFOA7TNA9
Date:
City or Town of: 0
To the Inspector Wi es:
�
wI
2cation
this application the prrdersigned 'ves �� f his or her ' tiPn to
rfo the a tri w rk c below.
(Street & Number) f,
N
a
wner'orTenant y� `
rA fGG����1�0'1 /1 I
Telephone o.
owner's
Address
r
0this
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permit in conjuncts wita bu ding permit? Yes
No ❑ (Check Appropriate Box)
of Build[oge UtilityAuthorizationNo.
mfisting
Service Amps / Volts Overhead ❑
Und rdg ❑ No. of Meters
w Service Amps / Volts Overhead ❑
Undgrd ❑ No, of Meters
Number of Feeders and Ampacity
Loc on and Nature of Proposed Electrical Work: 14Pa
D 1Z i S
No. of Recessed Luminaires
W ..•w WU•.ta
No. of CeIL-Susp. (Paddle) Fans
mo'e ffjov oe warvea by the inspector of wires.
No. of ota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
of Luminaires
SwlMining Pool Above
eNo.
ottrgency Lighting
rnd.❑ d.
Bae Units
No, of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches L7No.
of Gas Burner
o. o etec on an
Initiatin Devices
No. of Ranges
No. of Air Cond. Tons
No, of Alerting Devices
No. of Waste Disposers
eat ump
um er
ons
o. o e outa ne
Total$
Detection/Alertin Devices
No. of Dishwasher
S ace/Area Heating KW
P g
un c pa
Local Connection ❑�
No. of Dryers
[[eating Appliances KW
ecu ty ystems"k
o. o ater
No. of Devices or Equivalent
Heaters KW
o. o o. o
Signs Ballasts
Data Wiring:
Na of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
a ecommun cat ons r rag:
No. of Devices or Equivalent
OTHER: '
Attach additional detail rf desired or as required by the Inspector of wirer.
Estimated Value of cc 'cal Work: d0 (When required by municipal policy.)
ork to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE E: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
N CHECK ONE: INSURANCE BOND ❑ OTHER [I(Specify:)
iify �! cet, under the pains and penaliks of perjury, that the in on this application Is true and complete
\FIRM NAME: LIC. NO.:
Licensee: Signature dl LIC.NO.:j�,D
(If oppltcabl er.-e in t fie 'c ue num er ii e.) O Bus, Tel. No. Q
ff
�! Address: (� Alt. Tel. No.O •Per M.G.L. c. 147, s. -61, security work requir Depamnen o Public Safety "S" Licc e. Lic. No. O
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner ❑ owner's a ent.
Owner/Agent
Signature Telephone No. PERbtIT FEE: S
P
TYPE OR
PRINT
CLZARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Yamquth
JOSSTTE ADDRESS �,v7 r DATE S' !K PERMtT N
S rL i( OWNERS NAMEaIr vro r 0 vQnn(
OWNER ADDRESS � f Sv n L/a7.
• • • y•0 ■
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PLANS SUBMITTED; YES ❑ NO ❑
I haw a current &Wft)mjm= PoUcy or Ms wbstantlal u�tIRAN1: COVERAGE
rif�ctr "M°b m9ents of MGL Ch.142
Eyou haw ctwdrod Y� please In�caa ttre typ, a cowrag. cl�ddtg tlt. approprype I>oa bebrk
lueulTY INSURANCE POLICY [ OTHER TYPE INDE WIW
WN OERS INSURANCE WAIVER; I am aware Mcarua BOND
Massadauetb General and that my slgnapae on ft Prat appl a ft ng '°�� �► P
SIGNATURE OF OWNER OR AGFrur CHECK ONE ONLY: OWNER ❑
i"APR 06 2012
142 of the
BUILDING DEPT
I hereby W* fW al of the details sad Inbm dm I haw Xbnftd (or enEared
KrawledQe and that d pltanbirq wak and Insbdatbra performed wder the pw M Issued br ft spokom vM bo Inw 8"=nb b the bat of my
pn iWm of ltr Mapa&&Mb $(ib RROV Code end Chapter 142 of the Geoedl Dw%with al Per&Wd
PLUMBER NAME o wt So laws
LICENSE/ d-ti33 �iliL vtr/�
COMPANY "E u S �,* SIGNATURE
n r rn ADORES& ........../a>7rr S
CITY' Sr acnn�EZ=ZZI STATE �np-
ZIP o t� FAX
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MASTER 0 JOURNEYMAN CORPORATION ❑ f PARTNERSHIP [j
1..1"1 1. I fir.
121
yr ,
FAV
Commonwealth of Massachusetts
Sheet Metal Permit
Date: 3 Permit # I NI9
Estimated Job Cost: $ ID-66) -O / Permit Fee:
Plans Submitted: YES _ NO q Plans Reviewed: YES _ NO
Business License #" 11 SL7 Applicant License #
Business Information: Property Owner /Job Location Information
11 wkpI� 40Nf of // P
Name: to ckc1 L& P IA' , �� � � . Name: � > L4 t. 'l l S rt A _
Street: b) Nt.13 160c�,6% 2 Street: a-�-1 So•cK S pi-s- .
City/Town: r�r1 6aL63$ city/Town: cJt)L,,,'►\n o*t)�Ly
Telephone: �S 0 `i - it `j V V Telephone:CSO� ) 3 ` y - % SS- b
Photo I.D. required / Copy of Photo I.D. attached: YES _ NO_
sarrmrrw
J-1 / M-1-unrestricted license f
J-2 / M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less
Residential: 1-2 family_ Multi -family _ Condo / Townhouses _ Other
Commercial: Office Retail Industrial Educational
Institutional _ Other
Square Footage: under 10,000 sq. ftover 10,000 sq. ft. _ Number of Stories:
Sheet metal work to be completed: New Work: _ Renovation: X
HVAC _ Metal Watershed Roofing _ Kitchen Exhaust System
Metal Chimney / Vents _ Air Balancing
Provide detailed description of work to be done:
UtV%,y (-tv�.S %% t... ` C,V'LJ'OJ✓0 S
RERIDENTIA1 nt iCT TIG "MESS
TEST REQUIRED
S3ly U t5 ,,,,,•& wi ui< cnergY LOU requires leak testing
of ducks Installed in Non Conditioned Spaces. Two options
or Roug In Test
04 201-0 An Approval Certification is required from an auth4dzed
dNGDEtJT Certificate of occupancy or final approval of the work issue
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch.112 Yes 2� No ❑
If you have checked Yes. indicate the type of coverage by checking the appropriate box below:
A liability insurance policy P3 Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
- Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this boxQ, I hereby certify that all of the datalis and Information I have submitted (or entered) regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit Issued for this application will be
In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General laws.
Duct Inspection required prior to insulation installation: YES NO
Date
Date
Proeress Inspections
Comments
Final Inspection
Comments
By
❑ Master
Tina
❑ Master -Restricted
Cityfrown
❑Joumeyperson
Permit #
❑Joumeyperson-Restricted
Fee $
Inspector Signature of Permit Approval
Signature of Licensee
License Number.
Check at www.mass:noLrtri{!!
0
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO FORM PLUMBING WORK
CITY Farmouth MA. DATE 1 l3 PERMIT # /3-1429
JOeSfTE ADDRESS 1-) 56.jk OWNER'S NAME Sa r p V g n n
P OCCUP
ADDRESS TEL- FAX-[ ,
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TYPEOCCUPANCY TYPE. COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW. ❑ RENOVATION:19 REPLACEMENT. ❑ R/Ph PLANS SUBMRTED: YES [I N04�]
FD(UTRES I FLOORS-+ esnt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB —
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GASIOILISAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
D WASTE GRINDER UW r
FLOOR / AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK a
LAVATORY L
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET a
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WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
I have a current iabit' insurance policy or Its substantial eqwva�Cwhi COVERAGE
the requirements of MGL Ctt 142 YES NO ❑
f you have checked = please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY fg OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts
General Laws, and that my signature on this permit application waives this requremeu.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑
I hereby certify that all of the detalls and information I have submitted (or entered) regarding INS application are true and amurate to the best of my
Knowledge and that all plumbing work and Installations performed under the Issued for
permit this application will be In compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Lawn
/
PLUMBER NAME v< < LICENSE # (,�
,206 SIGNATURE
COMPANY NAME a u{ I /14 tj IADDRESS:
CITY`:E 1 r`r1iS ZIP: U 6 d FAX-
TEL rbe _ G 3b`t-gYp6 EM L ro nha we- C i.,n
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MASTER ❑ JOURNEY [fit Co # ^
PARTNERSHIP ❑ # �J ❑ #
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TYPE OR
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CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
l cur
CITY:�C�1� �f�f�w�n MA. DATE: � as 13 PERM(TU
JOBSITEADDP,ESS: 9-11 S6"h S6 r< Dr OWNER'S NAME Sur( 0" SAwd 5
OWNER ADDRESS: TEL: FAX
OCCUPANCYTYPE: COMMERCIALEDUCATIONAL ❑ RESIDENTIAL El
NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO
APPLIANCES? FLOOR—
Bsmt
1 1
2
1 3
4
5
6
7
B
9
10
11
12
13
14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
(•i cee e�3 90
INSURANCE COVERAGE
have a current liabil' insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ❑ NO ❑
If you have checked YES please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
ot have the msur�nce coverage required by Chapter 142 of the
OWNER'S INSURANCE WAIVER: I am aware that theFisp;�
Massachusetts General Laws, and that my signaturepplicationwavesthisrequirement
1111 2 2013 i I� CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT I
hereby certify that all of the details and information I have submitted (or entere regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
�Q1°1V�e I
PLUMBER/GASFfTTERNAME: �o� LICENSE —16 W p 'SIGNATURE
COMPANYNAMEAq�� �it�w�p�aS•�'tADDRESS:
CITYSTATE Mt'7 ZIP: FAX
TEL: �So�)3sr Isr CELL: (lib 3&Y-9 EMAIL: fbe) ka9ruC'Cyw%ralj: rjer-
MASTER bt JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION ❑ i PARTNERSHIP ❑ x IL ❑ R
ROUGR CA5 TNSPE,CI l —N NOTE,S THIS PAGE, FOlt TINSPECI'Olt USE, ONLY IjINAL INSPCCI'ION NOTI?S
Yes No
THIS APPLICATION SERVES AS TIIE PERMIT ❑ ❑ �'i D 'n v —7 /
FEE: b PERMIT 1
PLAN RTVILN NO'rES
Page 1 of 1
Hall, Lee
From: Sawyer, John
Sent: Wednesday, July 03, 2013 3:50 PM
To: Hall, Lee
Cc: Armstrong, James; Simonian, Phillip; Grylls, Mark; Arnault, Andrew; Elliott, Ken; Brandolini,
Jim
Subject: Surf and Sand Hotel 7/1G//J — /-M
Follow Up Flag: Follow up
Flag Status: Red
Hello Lee,
On 7/2/13 Andy and I inspected the Surf and Sand, 277 South Shore Dr. and required the following corrections
with deadlines assigned to each one; obviously number one pertains to your code but I wanted to be firm in
setting a correction date: (There is a Carbon Monoxide System Installed as part of the fire alarm system)
1. Single wall exhaust pipe from gas water heater in basement is corroded and leaking (Bottom of stairs
under the lobby desk)(Damage to pipe is where it enters a double wall section of pipe to the left of the
v(eater) Informed maintenance person that a licensed plumber must make repairs. Correction date
1�/ 1
2. All fire extinguishers have exp' '
3. Missing 110 Volt smoke detec rrection date 7/2/13
4. Asked for a copy of the annual ed or faxed.
C�
jt �3
4Jonathan E Sawyer .
Captain Inspector
Yarmouth Fire Department
508-398-2212 X-220
�- . �� �stirT s;T 1,�.s?fers6 MoT s
13 //
� s� s��z� �iP� %� °�` /'�s,�rf/ �dl2rP,�f �� /,sT`f>✓T
6:;4
fl
7/17/2013
/
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
/ -6V3
`' DATE i PEPJJJT
CITY 5 1 4�1` w� n Ll`t MA.
JOESITE ADDRESS S S t! r '09. OWNER'S NAME S _ 1011 ` %n-/ eL0,A%
"
pOVO4ERADDP.ESS
TEL 14 5�3'i. FAX
TYPE OR
OCCUPANCY TYPE COIv1\AmCIAL+F EDUCATIONAL ❑ RESIDENTIi AL.®
PRINT
NEW. ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ElNO ® `
FIXTURES 7. FLDOP.—
ISS191
1 I
2
3' I
4
5
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7 I
B
9 10 I 11 12
13 I
14
BATHTUB
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DEDICATED SPECIAL WASTE SYS
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INSURANCE COVERAGE:
I have a currant Pablilty nsurance pollcy or its substantial squlvalantwhich, meats the requirements of MGL Ch.142. Yes ❑ No ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE SOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDENhIITY ❑ BON ❑
OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not hava tha insurance coveraga raqulrad by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to th.
best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this application will be I
compliance with all Pertinent provision of the Massachusetts State Piumb'mg Code and Chapter 142 of the General Laws.
PLUMBER NAME �� 0.0 P, SIGNATURE �. �/
UC # 163 MP a JP ❑ CORPORATION PARTNERSHIP ❑ LLC ❑ #
COMPAM' NAME txAu1 ADDRESS: Z
CITY �3 STATE ZIP 01LL3k EMAIL
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POWNER
TYPE OR
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CLEARLY
MASSACHUSETTS UNIFOPNI APP'LJCATION FOR A PERMIT TO PERFORM PLUMBING WORK
CrIY h�1Nn`�� LAI 1� MA DATE L PEPJvNT#
JOESITE ADDP.ESS, a9 / SO l, Sltt d OWNER'S NAME S _ t)
ADDRESS TEL 3 9 V - 4 Si S" . FAX
OCCUPANCYTYPE COIA4EP,CIAL4 EDUCATIONAL ❑ RESIDENTIAL,®
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INSURANCE COV-ERAGc:
have a current iablity Insurance policy or its substantial squivalentwhich, neets the requlm-narrts of MGL Ctr.14L Yes ❑ No ❑
IF YOU CHECKED YES, PLEASE INDiCAi ETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOXBELOyd
'LLABILiTY INSURANCE POLICY ❑ OTHERTYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the lnsurancs coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑
or
l hereby certify that all of the details and information I have submitted for entered) regarding this application are true and accurate to th
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be I
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142Uof the General Laws.
PLUMBERNAME o~� t`! tAQv,4 SIGNATURE_
LIC # 163 3a up a JP ❑ CORPoRk noN PWI NERS`HI,P LLC ❑ #
COIPANY NAME �A CLA \d l i',b� 't y� ADDRESS
CRYOI.sTATEMA 21P OZLA EMu: 4-do,,4$t% k � Cb%m- kas�
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DELL — _—
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121/2015 SlipGen- Portal Hone
IL Town of Yarmouth
Template [Building Dept]
Slipsheet Identifier [sg172071
Document Category Building Permits
Map -Block Number 026.127
Street Number
0277
Street Name
SOUTH SHORE DR
Department
Building
Parcel ID
3333
Backfile Batch Scan
No
Document?
Additional Naming Info
Index Operator
Operator, Yarmscan
Date - Time
2015-01-21 - 10:50
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