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Home My WebLink AboutBLD-19-001568 -.X RECEIVE ��4 - - ice Use only r7 ) YAR'70 - ' mlili♦- /7-07)/ k. 6g 3e , 018 C Fl_ of SEP 'Amami ^'tth .L.t s,d.' I BUIL ING DEPARTMENT' - - Permit expires ISO days from . By: __ issue date EXPRESS BUILDING PERMIT APPLICATION E Ci E I V E D' - TOWN OF YARMOUTH Yarmonth Building Department R E C E I V E 4 2018 1146 Route 28 SEP 1 +, South Yarmouth,MA 02664 - SEP 1 - 018 •AR . (508)398-2231 Ext. 1261 - D �— - . -3 p, / _ k . BUILDING DEPARTMENT r-' t ION ADDRESS: 6 C�� O P ey: • • ASSESSOR'S INFORMATION: , " . - . " ' . Map: - i 3 3 Parcel: / t, • OWNER: •"•- "O‘r%A, GODC.t> ,' 3 S -C ..�Ot Pl. ., NAME - -L PRESENT ADDRESSTEL # CONTRACTOR: •act, + K•CA AnJj ets2L&L--- n gl.('.....1 ...rmi tom. Soi. s&-start NAME . • MAILING ADDRESS t TEL.# Residential 0 Commercial Est.Cost of Construction$ SV 0--C"--) ' , Home Improvement Contractor Lie.# ' 13 9 //l V ' Construction Supervisor Lie.N I OD ( &cl ' Workman's Compensation Insurance: (check one) • - - - - - "" - . 0 I am the homeowner ^-,D aI am the sole proprietor - )1(.1 have Worker's Compensation Insurance . . teInsurance Company Name: Arndt.i,ice- C,4.velta--- ' ' - . Worker's Comp.Policy# - . WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Z-0 Replacement windows:# '4 Replacement doors: # . , Roofing: #of Squares Si- ( pi-Remove existing'(max.2 layers) Insulation Old Kings Highway/Historic Dist.,,(.rLrl)Replacing�( like for like Pool fencing ' • 'The debris will be disposed of at: "{OW vn-6‘111.�, ,(}vim 0s:_ III Location of Facility I declare under penalties of perjury that the statements herein contained am 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 0 L Ch.268,Section 1. ' Applicant's Signature: 4 .lt • Date: 917i/tick. Owners Sin rt or chment) ` QV' Sign ( • �Oy �' ,�� Date: -1' hi �s t Approved B . .�'� ��/ . - . . . .. Date: ((( �/ 4, :uildmg 0111 gn- EMAIL ADDRESS: - Zoning District: Historical District: 0 Yes D No Flood Plain Zone: 0 Yes 0 No . . .. . , , Water Resource Protection District: '' 'Within 100 ft.of Wetlands: ' • 0 Yes 0 No 0 Yes- 0 No - .. -- - 41 it • The Commonwealth of Massachusetts .=ate g'i Department oflndustrialAccidents ' Congress Street, ite • 5l/c z" 1 Boston,MA 02119-2017 • 0 �Zi www.massgov/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): 424Qr-4– CL <Cs Address: • I OZ- k• City/State/Zip: A ret, sT0-4-- Phone#: sae 3 4- s •-e ry Are you an employer?Cheek the appropriate box: Type of project(required): I.[Y4 am a employer with 2— employees(MI and/or part-time).* 7. 0 New construction 20 1 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 ahomeowner doingall work 9. ❑Demolition ❑ myself[No workers'comp.insurance required.]t 4❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance•t 6.0 We are a corporation and its officers have exercised their right of exemption per MOL e. 14.0 Garr 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 end 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 andfob site Information. I Insurance Company Name: 4.r t 4t c (-1>k I ; . • - Policy#or Self-ins.Lic.#: W C i 00001 SO \ Expiration Date: ] ' i�[ ��,// Job Site Address: 2 CO – 1?QA r City/State/Zip: \4cctrye.Bt,,AL. i 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. Ida hereby(Of de the p•'y ,d p J e es of perjury that the information provided above Is Owe and correct. • i_nature� �ra �a�� late• 4 • — ---- Phone#: SD? 3Fs'S '-ltl .(2 Official use only. Do not write in this area,to be completed by Lary 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#: °Fri„c TOWN OF YARMOUTH __ 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 RECEIVED Telephone(508)398-2231 E . 1292-Fax(508) 398-0836 u • REC6T3 FZING'S HIGHWAY HISTORIC DISTRICT COMMITTEE SEP 1.0 2018 SEP 1 12018 YARMOUTH• APPLICATION FOR OLD KING'S HIGHWAY TOWN CLERK CERTIFICATE OF EXEMPTION SOUTH YARMOUTH, MA 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: / --•• `` A ,� Address of proposed work: 3 g +"Crt d V N�Gtek Map/Lot# 113f}Owner(s): X1 } Owner(s): 1 esSOL T n Phone#: 11 g g 7 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address:esYear built: Email: y3\n_aj,,,5� 6-5 Pt/�1�,e ttaCrv6�� Preferred notification method: x Phone Email Agent/Contractor: ,�^'t i , `• arc`'-ANN-( _ 1�. t Phone#: Sb 3 is 9S _ Mailing Address: r 1O' — c4 \ r.KA,\3�t c . �{C�.1�1�- AM 02.411 Email: r'o Gk t . Coo cr<) Co Cr'.C.G. .Da Preferred notification method: Phone X. Email Description of ProposedWork(Additional pages may be attached if necessary): ,/UL,M OVA o& /Vptms c C'OOPt S ickkao �`L� S t ( K.s is W s p4249 s s sa, .e sawAPPROVED CP k 0-10 tit.) S _ 5 e c 4- 4 A-e.LED SEP 10 2018 YARMOUTH // ��i/� OLD KING'S (IIGGHWAY Signed(Owner or agent): . Date: �Q > Owner/contractor/agent is aware that a permit may 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: /'/U-1 S /proved _Approved with changes _Denied g Amount ab Reason for denial: Case: 4_37 Rad by: fit/ Date Signed: 9��/Z9/, Signed: 07 APPLICATION#: • V5.2017 'frorrl- . A t . -1-v a D.. '°/� a St\ LIL 1.0)RECEIVED11 SEP 10 2018 • RECEIVED YARMOUTH OLD KING'S HIGHWAY SEP 112018 Re SOUTH WN CLERK (A bkk L)*, CVO YARMOUTH, MA Gasemet-�- ' -L6 - DH b/b APPROVED SEP 102018 , YARMOUTH OLD KING'S HIGHWAY J 1 10/, ,i b • L L' .•••• 111.11 a !. Commonwealth of Massachusetts • Division of Professional Licensure Board of Building Regulations and Standards , Constructicyl,Slip s9rSpecialty CSSL-100134 " , ; E)tDires: 03/16/2020 l es C• t ' ROBERTHC 102 WnjE AVE + ; -4 BREWSTER STER MAi02631' Commissioner 4' mea/c4 loffawear. C'f`se^f u5A's�."13 Af•airs Business Regulation • HOME IM'i ROVEL't COATlACT CR . • TME:Supplement Call '?emstratigr.1 "sc'rian Iti/03/2019 . ROBERT H.CHA61BER1..i IrtC ROBERT H.CHAMBEF `_X' 102 WHIFFLETREEAVE== • BREWSTER,MA 02631 =' Undersec-etary • 3 •F‘ G.:54 • • The Commonwealth of Massachusetts 1 • r— a=„ ,�et Department oflndusfrialAecidents ce =•-• f. 1 Congress Street,Suite 100 =_T • Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumhers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: ROBERT H.f`H4MBER3,INC 102 WHIFF RE YE City/State/Zip: BREWSTF Rn . • Are you an employer?Check the appropriate box: Type of project(required): 1.� t J am a employer with . employees(MI and/or part-time).* 7, 0 New construction 2.0 I am ri sole proprietor of partnership and have no employees working for me in s. 0 Remodeling any capacity.No workers'comp.insurance required]• • 3!DI am a homeowner doing all work myself.No workers'comp.insurance required.] 9. ❑Demolition 4.01 am a homeowner and willbehirin contractors to conduct all work on100Buildingaddition Bmy property. I will • ensure that all contractors either have workers'compensation Insurance or am sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Pltmtbing repairs or additions 5.Q I am a general contractor and I have hired the subcontractors listed on the attached sheet 13.0Roof repairs These sub-contractors have employees and have wodren'comp.insurance: 6.0 We are a corporation and Its officers have exercised their right of exemption per MGL e. 14.❑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 am doing all work and then hire outside contractors must submit anew affidavit indicating such :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have • employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that Is providing workers'compensation insurance for my employees. Below is the policy and Job site information: (��Q �� Insurance Company Name: ' `•�9 NALL o5\'ls— ' Policy#or Self-ins.Lic.#: (AO) a2Gbak V t Expiration Date: t [ (• Q , }� Job Site Address: 3.2f 61t City/State/Zip: 47t �-1r -f'�/ •f cRt.� • Attach a copy of the workers'compensation policy declaration page(showing the polity nu/Aber and expiration date). Failure to secure coverage as required under MGL e.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 Sae 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 cerd.. , t/ p. C (p :taffies of perjury that the information provided above 'le and correct. Signature: tJ Date: "i/ ' '/ /i” • phone#: Sp'? 3RS �S-IC. Official use only, Do not write in this area,to he 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#: