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Home My WebLink AboutBLD-19-2640 Y a Office Use Only I O ?..• erm Pit# ' S wAt, ! n w une rd p c' termitd2eitxepires 180 days from 3E-01'1g —Obd\ / . EXPRESS BUILDING PERMIT APPLICATI IR E C E I V E D TOWN OF YARMOUTH 1 nD✓ I t 71X Yarmouth Building Department teT- }8--� 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT. aY �/ (508) 398-2231 Ext. 1261 CT CONSTRUION ADDRESS:/9 Azgi eA Z ,/t/e Se445 ",fre icvfg • ASSESSOR'S INFORMATION: / • Map: Parcel: OWNER: illi *loS€A et/en/2,9,d 9ARGiroviz dd .nfAirdesi'/'249 ev Poo-77/-fc.29 NA PRESENT ADDRESS TEL # -NrRACTOR: SMO bJ//44M 6 ,q Z&, Sol S6 7-e9 i' 7 / NAME MAILING ADDRESS TEL# lIff sidential 0 Commercial Est Cost of Construction$ 3 9610"478 Home Improvement Contractor Lie.# `/7 CS Construction Supervisor Lie.# e7 V.S.—P00 Workman's Compensation Insurance- ( eck one) L....7.--0 I am the homeowner % I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: /\ Worker's Comp.Policy WORK TO BE PERFORMED b Tent _ Duration (Fire Retardant Certificate attached:Ilk,j- k Wood Stove r ei Siding: #of Squares 44 D Replacement windows:# I U Replacement doors: # 'Roofing: #of Squares /Y ( t,..-)Remove existing* (max.2 layers) %he, Insulation -/7 Old Kings Highway/Ristoric Dist. (( tgepiacing like for like Pool fencing 'The debris will be disposed of at if//✓/4 -571.417�g7G!D,el /H SC&— SO 9''/o yyX` 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 Simmture: iii #/ ,,�sx�l f Date: /v/��0/�OIeR Owners Signature attachmen f//{.��,,, // / Date: / Approved By: //e t-a�e,� Date: //— /—"ea-- Building 6666$$$cctrttal(or designee) EMAIL ADDRESS: Zoning District _ Historical District 0 Yes 0 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 • • The Commonwealth of Massachusetts t�= .cyt_ '/ Department oflndustrialAccidents t I f. 1 Congress Street,Suite 100 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): rimy ea /4,00 .'0 Address: 9 F2 az.we /en City/State/Zip:,A,✓CNesfric Coe/ti Phone,#: 864—7029. 5'x97 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or pan-time).• 7. ❑New construction 2.0yem a sole proprietor or partnership and have no employees working for me in 8. [l..8ratodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work t 9. ❑Demolition ❑ myself.(No workers'comp.insurance required.] 4.01 am a homeowner and will be hiring contractors to conduct all work on mY ProPel I will 1 ❑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 I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13.[}Roof repairs 6.0 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.[No workers'camp.insurance required.] • 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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(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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: f7,p-c ,/ -C Date: /o/3%2eVc ' Phone#: 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#: /. . z � °f" .So TOWN OF YARMOUTH tt $ 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 ,� " r. Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 ibe?kh Vo�1 • RECEIV5Th KING'S HIGHWAY HISTORIC DISTRICT COMIII EIVED OCS 312018 APPLICATION FOR OCT 3 0 2018 CERTIFICATE OF EXEMPTION TOWN CLERK YARMOUTH pUTH,MA LNG'S HIGHWAY Appli igihib y made for the issuance of a Certificate of Exemption under Sections 6 a O� o C DIh pter4 Acts 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: n Address of proposed work: /3 /7 2,41 eg LQ v e .SOc/ffrl �/�QJf,1y pioap/Lot# Owne s): /270979y • eI.,Cie/ANL/1 Phone#: 76a- 7;9-w/399 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: Cr2oe_e /cl0 Zrsene e /t er9Nsze,sP -f Year built: /9sy Email: / Untie.. Preferred notification method: Phone Email Agent/Contractor.. rc7/ 1vtt/ /00191.4440 Phone#:779-262- 9.3773-- Mailing SSSMailing Address: 2 5 eVocIt/wj /8/Rl7 A,4jva a19S?L /T/2blrloy7`.rr Email: 1 Preferred notification method: l/ Phone Email Description of Proposed Work(Additional pages may be attached if necessary): gepL4VA /o ,fx',n gq a',,v.anJs/ a.0/7/ /cNeaflti 'Z'oC ,9,c. eve/a SirSn,0.-p.i r fl voegsen>,/�nan"a ii'c'nniS.w.sd Pik//vfeX�'en/,rc- 1r5eii'f1 &.&' te/ AND dvvyecYase 7911F6RA9( ,s-74,,,, /!itiJ feeReoc 61o0-2 N'tAztpeef Ast,k-er enfief!/tecfynmL SI.I.NJLeS Re Aid been. 1) iis7%dGacoA eZee, Signed(Owner or agent): A/1c+ Date: Ai —30 -"IF— > 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: /b--3o`7 Reason Approved _Approved with changes_ _ _ nied Amount $90 for denial: AP fp \�l/LGA Cas 5K . Ja7a OCT 31 2018 Revd by: ZerI/ YARMOUTH p OLD KING'S HIGHWAY Date Signed: /C/3 ZOiSigned: , �• APPLICATION#: Jd --E//9 V5.2017 1+J M riommontreafrif alb fln.uaclruem Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR r r ;Registration: '178253 Type: ,; Expiration 3/314018 Individual • STANLEY RO r 6O , STANLEY ROMANO = ' 25 MOCKING BIRD LANE W.YARMOUTH,MA 02673 Unite retary Commonwealth of Massachusetts ®; Division of Professional Licensure Bard of Building Regulations and Standards Constructbn'Supervisor • CS-045800 Eispires:05/20/2019 •WILLIAM J KROUZEK,111' , 725 PLEASANT ST#511 NEW BEDFORD MA 02740 Yl Commissioner G.�