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Home My WebLink AboutBLD-19-001783 ot �. Office Use Only '�I :'�•'•f"'G ! ��- e Permit# 1 C' �j( ..�1�!'I ^]: Ammmt✓0o - . P �x Permit expires 180 days from l issue date EXPRESS BUILDING PERMIT APPLICAT Ch.'• C E I V E D • TOWN OF YARMOUTH Yarmouth Building Department SEP 25 2018 1146 Route 28 • South Yarmouth,MA 02664 BUILD e 4 • i ENT (508) 398-2231 Ext. 1261 y' l/ CONSTRUCTION ADDRESS: S2? 2t 60• V aA ni 0 ciriniparfr 444s, 626 9-Se— ASSESSOR'S INFORMATION: • Map: Parcel: OWNER £oboeirt Ellice I 1: to; R-1".64 VA yin, fft1cw!'f- Apr 024,93-- .511:01•10. WI s NAME PRESENT ADDRESS TEL It CONTRACTOR: NAME - MAILING ADDRESS TEL it )(Residential ❑Commercial Est.Cost of Construction S A DOJ Home Improvement Contractor Lie.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) 3k I 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:# Is( tslider' Replacement doors: # 2 5-Invents I do., AR000fing: #of Squares ( )Remove existing* (max.2 layers) Insulation &\) ic2/4Sld Kings Highway/Historic Dist.s ( )Replacing like for like Pool fencing *The debris will be disposed of at )(PAPS tit-/ Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief I understand that any false answer(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: Date Owners Signature(or attachment)�' ,17...dt_ Date: 9las Lp(c/JApproved BY Date: l—��-/j�Buil.••I it .. (or.-.ignee) DDRESS: Zoning District Historical District 0 Yes 0 No Hood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 R of Wetlands: ' 0 Yes 0 No 0 Yes 0 No The Commonwealth ofMassachusetts / 1,- '1 = '� Department of Industrial Accidents �1= I Congress Street,Suite 100 Boston, MA 02114-2017 • itIc.�, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 1 Please Print Legibly Name (Business/Organization/Individual): 2..26 eft Address: Co'? 203 - City/State/Zip: \I,,t„ o }c peer: MP . Phone#: ay• q �IS Are you an employer?Check die appropriate box: Type of project(required): 1.❑I am a employer with employees(fall and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling • any capacity.[No workers'comp.insurance required.] 3.�I am a homeowner doing all workmyself t 9. 0 Demolition [No workers'comp.insurance required.] 4. I am a homeowner and will bemy property. I 10 Building addition ❑ hiring contractors to conduct all work onwill entre 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 5.01 am a general contactor and!have hired the sub-contactors listed on the ached sheet. These sub-contractors have employeand have workers'comp.insurance.: Roof repairs es 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[Na workers'comp.insurance required] 'Any applicant that checla 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 onside contractors must submit a new affidavit indicating such. :Contactors that check this ha must attached an additional sheet showing the came of the sub-contractors and state whether or not those entries have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am rot 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(showing the 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 certify.'underr the pains and penalties of perjury that the information provided above is true and correct Signature: ,r-r/r� /p p(I Date: � 2'{ $i Phone#: 5-o .;t-/O. til c Official 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Pt • 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,MOL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance ' requirement of this chapter have been presented to the contacting authority." Applicant Please fill out the workers' compensation affidavit completely,by checldng the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es) 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 Accident for confirmation of insurance coverage. Also be sere to siva 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 Accident. 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/Iicense 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 Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 r• Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia Av:uIll • of Y _ 3` x ,14TO6 TWNo�OFTH R oARMUTH, MA 6OU1T1- RECEWED :, ` Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836 n SEP 2 0 2018 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEEYAtRMOUTH OLD KING'S HIGHWAY APPLICATION FOR CERTIFICATE OF EXEMPTION • Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: rl Address of proposed work: Sa a kr ( A '/tv rnou earl— M l r Map/Lot# Owner(s): ( o b p rf, errei[t Phone It: 508 a 410. ti//5- All All applications must be submitted by owner or accompanied1by letter from owner approving submittal of application. Mailing address: 8'Jb) (2t b-1. j(LCn1CLrft\ OOr& Mil O267s- Year built: /983 Email: bt^tTf 1ln br1, l (x'l6hwtrai l. C-orrt Preferred notification method: Phone /X Email Acient/Contractor: K-GI( ..b Phone#: JC��•a'T/i.7 3-3 Mailing Address: r22- ( nb.. 64 . Alli4nmoe/LI/o re÷/ A Email: ked^I (o ca 2—CP R 0 3 mall. teen Preferred notification method: Phone X. Email Description of Proposed Work(Additional pages may be attached if necessary): gp/ All wrndouo s RECEIVED APPROVED RECEIVED 2.12018 SEP 21 2018 TOWN CLERK YARMOUTH SOUTH YARMOUTH, MA j� OLD KING'S HIGHWAY Signed(Owner or agent):/�P`r b iF (/J-gf Date: c1//.g" > owner/contractor/agent is aware that a permitUmay be required from the Building Department.(Check other departments,also.) > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date: �D—/� Approved _Approved with changes _Denied 5 Amount CO Reason for denial: Cash/CK#: R`` tu:>tt-,2,11es Revd by: Date Signed: 9 7203' Signed:a�a 8 - E 1 0 4 APPLICATION#: V5.2017