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_ - Permit expires 180 days from `
• issue date
EXPRESS BUILDING PERMIT APPLICATIO►
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28 NOV 07 2018
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261 BUILDING DEPARTMENT
CONSTRUCTION ADDRESS: /1 ( O/a6s 1?gq y R 15
ASSESSOR'S INFORMATION: I •
Map: / .5/ Parcel: Z
on 57 fr L/s7 9 Eza, so,t/ ko \thr/ Iy 6/7 GIS 2918
NAME
� / p PRESENT ADDRESS TEL. # ? -7�
CONTRACTOR:' 1 F—o/`.a((S S 7 CZ�R_m!I y L.+i/ Yc TO g 3 cc 4/Z S
NAME - MAILING ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction S /Z t U OV
Home Improvement Contractor Lic.# l b1-1 Q b P
L 1 i Construction Supervisor Lie.# U q pin
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ I am the sole proprietor XI have Worker's Compensation Insurance ,,./,�w
Insurance Company Name: A 14 Atir✓,pt-.. Worker's Comp.Policy# GG —> 'SDOYSV7 3oIOA
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 'J Replac ent windows:# Replacement doors: #
•
Roofing: #of Squares 3 4 ( )Remove existing*(max.2 layers) Insulation
ISZ Old Kings Highway/Historic Dist. jpi.Replacing like for like Pool fencing
"The debris will be disposed of at /A RAA 4 t/T L1 l ) ,AA `
Location of Facility l
I declare under penalties of pee . • • e 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 d- or revocatio• • y • ense and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signatur: a Date: IN/ '('
Owners Signature - attac• ' Date:
Approved By: r/....------1
Date:
i) - hi
Building Official(or designee EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands: •
0 Yes 0 No 0 Yes 0 No
The Commonwealth ofMassadhusetts
•✓ ��_? ��/ Department oflndustrialAccidents
c_=e= .1 Congress Street, Suite 100
e = F4 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): WC4U4 CQe(/cheU!/lOA/
Address: g`7 cepa leg y 1_%AJ
City/State/Zip: 5 '4 jjipv-f 14—,44 Phone #: SOV 3C4Lj Ito c.
Are you an employer?Check the appropriate box: Type of project(required):
RI am a employer with 1 employees(full and/or part-time).• 7, 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition
4. I am a homeowner and will be hiring 10 0 Building addition
0contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. p0r'ROof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,41(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.
:Contactors that check this box must attached art 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: XI t,AA_
Policy#or Self-ins.Lic.#: ��te� CL —VDjGq 5,97-e4,..4 Expiration Date:
// /
Job Site Address: 1 ( CTr oy4�=' a l Ay go City/State/Zip: 7 Pvti2-7 l.,4/4
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 ce ' and r tl e ins and penalties of perjury that the information provided ove is true and correct.
Simatur . Date: 11
Phone# 5'(n 179 4 /Zn ti
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#:
• 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 ajoint 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-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 •
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 cine.
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
s,
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
. ( l`,tant'
.
o
• �; � c TOWN OF YARMOUTH /kEc
ci
e�,,,; , ;3 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone(508)398-2231 Ext. 1292-Fax(508)396-0836
RECENEBLD KING'S HIGHWAY HISTORIC DISTRICT COMM!
I-1-
iivdn,ouTh,
� SylGyW
OCT 232OIS APPLICATION FOR -�ti`
CLERK CERTIFICATE OF EXEMPTION
TO pUTH,MN
ApLciaggilideEreby 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: j�
Address of proposed work: ( t G-. : `-'2.i-r P() Map/Lot# /57/Z I
Owner(s): ` J V—' .- L / ST Phone#:64 Phone#:6Z 67f2
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 9 G7U_1?S u rJ le o \icL 0=5 /1/ Year built: / '1 7g
Email: '3 1 (-t5 rte? 0 Ada, ..
,c0 ^ Preferred notification method: Phone oC Email
Merit/ContractorMerit/Contractorr `\ CZ& (t< Phone#: 5-019 rig- / 70C
Mailing Address: (a-I C.4410?=Fns( !mac/ S `4,e,t e aCJ-('t4-
Email: -712C-.)‘<e, ',\ Ifs p)(beAm 01ST. Pref ed notification method: Phone Email
Description of Proposed Work(Additional pages may be attached If necessary);,
CAAA/6ra Pcte CotomTo LA,IO/14424. C k&CoAZf3kcK
M'dc i?o-T L Ora_ 20 Rft4 5 rits Ci
A 73 v zs r p kM /I
L'_.AVy g4ea-5 4.vl� 12 R,JCt 5rtet2 rrU 5tivia"Al-7T(�= �d4' =R
•
Signed(Owner or agent 1 , •
�Ilia Date: /0/7/Y
> Owner/contractor..- 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: /07 2' /pproved Approved with changes AP enis&
Amount , 00 Reason for denial: O
Cast. `767& OCT 22 2018
Rcvd by: YARMOUTHa 0\-11-.1(')
OLD KING'S HIGHWAY
Date Signed: CZL" Signed: C�
�����, APPLICATION#: a'E//y
V5.2017
From:Steve List<stlist67@yahoo.com> `1D!
•
•
Sent:Thursday,October 18,2018 1:05 PM
To:Troy Walls<troy.walls@comcast.net>;Troy Walls<troy02664@gmail.com> OCT
j 201:EV
Cc:Steve List<stlist67@yahoo.com> ARfviQU7H
Subject: 11 George Bray Road ��K�NG'S HfGqy
To Whom it May Concern,
Please be advised that Troy Walls of Wails Construction is my Authorized Agent to work on my behalf at
the property located at 11 George Bray Road, Yarmouth Port, MA 02675.
Sincerely,
Steven D. List
Owner RECEIVED
OCT 232018
'TOWSCLESOUTH MOUTH, APPROVED
OCT 2 2 2018
YARMOUTH
OLD KING'S HIGHWAY
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Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: individual
Registration: 105179
TROY WALLS Expiration: 07/15/2020
87 CRANBERRY LANE
SOUTH YARMOUTH,MA 02664
Update Address end Return Card.
Wm A 20M-O&17
9P S,n/nr'nnMw/IA c/C'/61kiektfria
Office of Consumer Affairs 8 Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:IndMdual before the expiration date. 0 found return to:
Realstration Egon Office of Consumer Affairs end Business Regulation
105179 07/15/2020 1000 Washington Street-Suite 710
TROY WALLS- Boston,MA 02118
TROY A.WALLS
87 CRANBERRY LANE
SOUTH YARMOUTH,MA 02884 Undersecretary Not valid without signature
Commonwealth of Massachusetts
®r Division of Professional Licensure
Board of Building Regulations and Standards
Con struetidn'Supervisor
CS-044847 Expires:07/05/2019
TROYAWALLS .., '11-�
S7CRANBERRYLANE
SOUTH YARMOUTH MA 0286 ''
Commissioner ✓'^` /�
AIM .M cfra��t,
Vl/GC — 3—CO S 577 ' z0I?A