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HomeMy WebLinkAboutBLD-15-004976 Office Use Only O 1 Permit# M cs.a� Amount Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATIO - TOWN OF YARMOUTH . E. Yarmouth Building Department __ 1146 Route 28 i APR 03 2023 South Yarmouth, MA 02664 508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: 1 71 ' IC1L L I(16 0 V f 4 I el J/1'. 0/ZG 1^ ASSESSOR'S INFORMMATION. Map: '7j /, 1 Parcel: OWNER: V � �t5S � C(0y kWes 1, 4(1ht5 gi 7/ _/ -5-C3 —042G NAME ! PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est. Cost of Construction$ 3/(PC), Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) NLI am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # 5' Replacement doors: # Roofing: #of Squares ( )Remove existing* b (max.2 layers) Insulation Old Kings Highway/Historic Dist. (i\)Replacing like for like al pr6v 31g3/, Pool fencing *The debris will be disposed of at: VC,f,.--. 1/t^N^ , Loc ion of Facility I declare under penalties of perjury that the statements herein containe. -. ue-and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or re ocation o license an. fpr. :..'. under M.G.L.Ch.268,Section 1. Applicant's Signature: / - Owners Signature(or attachment) �� ���..___ Date: - 3 sr Date: �l 3 2-Approved By: Building Official(or designee) EMAIL ADDRESS: Date: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: C Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes ❑ No 0 Yes _ No -- •iv\ • The Commonwealth of Massachusetts . la - � 1 Department of Industrial Accidents y�A•: iti 1 Congress Street, Suite 100 V . sz• Boston, MA 02114-2017 :._ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 3, L . C( 1_es ;, Address: t-( 1 frk/04 10CO3v,i 5 City/State/Zip: rf t, ,,,,I U 6 7 5 Phone #: S 6 C, ��`I qzc Are you an employer?Check the appropriate box: 1. I Type of project(required): employer with employees(full and/or part-time).* — ❑ am a em 7. 2.0 I am a sole proprietor or partnership and have no employees working for me in — New construction any capacity.[No workers'comp. insurance required.] 8. Remodeling 3. t2'I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 4.11I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. - 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.$ 13.❑Roof repairs 6-❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showi(showingthe policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi er the • nd penalties o but at the information provided above is true'and correct. Signature: "{, Date: K— 3- , -i Phone#: K "S c) 0if G Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing 6. Other b Inspector Contact Person: Phone#: o •'yq4 TOWN OF YARMOUTH Building0 Department BUILDING ����G ( 8)398-2231 ext.1261 Y�-w►T►.K�� PERMIT NO BLD-15-004976 PERMIT JOB WEATHER CARD ISSUE DATE .... ..2015{`s.�as..:..:...... .... . ( P)_ APPLICANT CLOHESSY JOHN M JR ' ..........-.. ..- PERMIT TO ,_.........Repair AT(LOCATION) 479 NORTH DENNIS RD,YARMOUTH,MA 02675 ZONING DISTRICT ' I �._____._.._____._____________._._____,_._______._._.__. R 40 Bldg.Type: Residential SUBDIVISION MAP BLOCK LOT _.-.-..--~-... 144.20 BUILDING IS TO BE: CONST TYPE !€ USE GROUP REMARKS 10 replacement windows,one replacement door(774-563-0426) CONTRACTOR LICENSE II I • AREA(SQ FT) 1,973,372454; EST COST($) 15000.00 PERMIT FEE($) j50.00 i OWNER CLOHESSY JOHN M JR BUILDING DEPT BY ADDRESS CLOHESSY LISA M,479 NORTH DENNIS RD 1 'YARMOUTH PORT iMA :02675 i PHONE r -- THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY-OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR -- PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE APPROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM MINIMUM INSPECTIONS REQUIRED FOR ALL APPROVED PLANS MUST BE RETAINED ON WHERE APPLICABLE SEPARATE CONSTRUCTION WORK 1)FOUNDATIONS OR JOB AND THIS CARD KEPT POSTED UNTIL PERMITS ARE REQUIRED FOR i FOOTINGS.2)PRIOR TO COVERING STRUCTURAL FINAL INSPECTION HAS BEEN MADE.WHERE ELECTRICAL PLUMBING/GAS 1 MEMBERS(READY FOR LATH OR FINISH COVERING) A CERTIFICATE OF OCCUPANCY IS AND MECHANICAL 3)FINAL INSPECTION BEFORE OCCUPANCY 4) REQUIRED,SUCH BUILDING SHALL NOT BE INSTALLATIONS. REFER TO DETAILED INSPECTION SCHEDULE OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTIONS APPROVALS OTHER: IIIIIIIIIII WORK SHALL NOT PROCEED PERMIT WILL BECOME NULL AND VOID IF UNTIL THE INSPECTOR HAS CONINPSECTIONS INDICATED ON THIS CARD STRUCTION WORK IS NOT STARTED WITHIN SIX CAN BE ARRANGED FOR BY TELEPHONE APPROVED THE VARIOUS MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED OR WRITTEN NOTIFICATION. STAGES OF CONSTRUCTION AR(1VF —N bk-- 1\62 f�) iminekailrs- - 3/a3) 3 OF•Y • . i c TOWN OF YARMOU o .A4 J, lf 11•fGROUTE28 K�rrA n t "s';' SOUTH Y,AR\M°UTlI AtASSACHUSE ' 2 : `°arMne+��(c)'; Telephone(508)398-2231 P I 1 :'006 r::" OLD KING'S HIGHWAY REGIONAL HISTORIC DISTRICT COM tITTEIYARMOU•;., '-- CERTIFICATE OF EXEMPTION OLD KING' HIGHWAY Application is hereby made for the issuance of a Certificate of Exemption under Section 6 and 7 of Chapter Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and onplans, drawings, or photographs accompanying this application, on pns, TYPE OR PRINT LEGIBLY u C q DATE cl-I 1 -O G ADDRESS OFOF PROPOSED WORK LI { Net' 1 OWNER �-k Ln C- 0L-c SS t ASSESSORS MAP# ASSESSORS LOT#HOME ADDRESS Se... t �� ticot„) TELEPHONE# r}r}y- S(,3-0-PC AGENT OR CONTRACTOR Hov ADDRESS TELEPHONE# THIS APPLICATION IS FOR EXEMPTION OF PROPOSED EXTERIOR CONSTRUCTION ON THE GROUNDS ( ) IT WILL NOT BE VISIBLE FROM ANY WAY OR PUBLIC PLACE. THAT: (?4 IT IS WITHIN A CATEGORY DECLARED ENTITLED TO EXEMPTION BY OLD KNG=S HIGHWAY REGIO DISTRICT COMMISSION, (Check applicable box) _U NAL HISTORIC PROPOSED WORK;DESCRIBE WO . EXISTING BUILDING. SHOWING LOCATION ON LOT,AND IF AN ADDITION IS NVOLV En LOCATIq1J�OF {{ to x Iz ,s1.t�l � `Si��Gi )A11 of SL'A les C{ lJboarei FFrdt1V wiK. dloo f G. o,)1'ntJWJ, ila,,,)^rir„ t cur% e.,� ) o��,er- 3 s,t 1s W 1 V� doer' on �ts't P ill m C•,rC cxcg}-„n3 l-lo,,c_ Fri � : st�(e� 0 °_1 T tV Signedc/./... / Owner-Contractor-Agent S ace below for Committee use. Received by OKHC The c Ificate is hereby Date �l /� APFF.,,:. i check# � ! � �/i ,, ,,,..,.;,.,:,Jt;.;,tiiE • By DDate APPROVED( ) DENIED ( ) 43 Prirnea nn l7ecyc,wq i'apyr O :11