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Home My WebLink AboutBLD-19-3162 jr �Y'qR i Office Use Only OF ,• .0 ; a A 4)itk Iq.� /4� O. .'.' 4. Amount • ? ire cps(y v...... r Permit expires 180 days from - issue date i EXPRESS BUILDING PERMIT APPLIC , E � V E p TOWN OF YARMOUTH Yarmouth Building Department NOV 16 2018 1146 Route 28 —ll South Yarmouth,MA 02664 DEPART ,i. + I OZ) (508) 398-2231 Ext. 1261 `' — -- CONSTRUCTION ADDRESS: 3(4 Rt \f o� 4u-e y p ASSESSOR'S INFORMATION: l / • 1�' Map: CI / 7\, Parcel: , �3 b OWNER: UOY1t 1.4. 'Q r' `J3 ENT t(L t eictzt 4'Ne_ 510# ` ?)6'Vr ( NAME fi P S ADD SS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL# / fn\) D'Residential 0 Commercial Est Cost of Construction$ t,EOM v V Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workmompensation Insurane ' heck one) I am the homeowner am the sole proprietor 0 I have Worker's Compensation Insurance i Insurance Company Name: Worker's Comp.Policy# SD, WORK TO BE PERFORMED SOfsQ -{"Q/15°62 Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove • Siding: #of Squares _/� Replacement windows:# Replacement doors: # 2 o Clipboard, ieh•nj.Irs ' / 'fLiit — / /CC/ Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation x. Old Kings Highway/Historic Dist. (' )Replacing like for like Pool fencing t� *The debris will be disposed of at (ri' e.e4.�� (Go (-p i Lte, �Q/41 q q sag 5)-C �a) b Location of(-p I declare under penalties of perjury that the stat ents 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 revo thin f license and for prosecution under M.G.L.Ch.268,Section 1. p Applicant's Signature: Vhf - Date: t e/1�//lj > Owners Signature(or attachment) 1 �� Date: ` V(,1( Approved By: .(� _ Date: II — a)- /ep�0 Building Official(or deli The) EMAIL ADDRESS: • Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100`R of Wetlands: 0 Yes 0 No 0 Y 0 No __Z� • 1 offThe Commonwealth of Massachusetts ; , 1 / Department oflndustrialAccidents diel=4 1 Congress Street, Suite 100 • 't�_ Boston,MA 02114-2017 z•lx�E� www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): /... :Art g epfte -- Address: 3 "f /,?ut/ /3q ,4 404 City/State/Zip:5' qrune l, pn966 f Phone #: Co F_ ))4 -- a-co Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.Eel am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that an 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other yet f/r 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 ant 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.#: // �J Expiration Date: Job Site Address j4 Alf Porte' } 44Q., City/State/Zip:.‘,.‘‘.( Attach a copy of the workers' compensation policy declaration page(showing the policy num er 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tl a pains and penalties of perjury that the information provided above is true and correct Signature: r Date: tO/rD/gi Phone*: J -- ) >4 ir° 1 Official use only. Do not write in this area,to be completed by city or town offciaL City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone 4: i of y� � 5t� _. TOWN OF YARMOUTH e [Jim 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 :1,—Edd Telephone(508)398-2231 Ext. 1292-Fax(508) 398-0836 p--ECEIVED RovO �D�hit S HIGHWAY HISTORIC DISTRICT COMMIIILTTTE NOV 20 20M 19 2018 2018 APPLICATION FOR YARMOUTH OLD YARMOUTH CERTIFICATE OF EXEMPTION OLD KING'S HIGHWAY KING'S ti HIGHWAY Application is hereby made o he issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973,as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: �/ Ila 3$ bN"Iwfts Address of proposed work: 3/1 1%,1,4(5,--c 4 C� / p Map/Lot# �1 Owner(s): 1:1nq (� ?- l Phone#: 5 Oa"'- ' --1/4—Thi All applications must b itt d by owner or accomp led by letter from owner approving submittal of application. Mailing address: 3 Q1 i 17UQ Year built: roX 0,26" 6Y Mt VII b\l'All Email: I o[ (CJ"' f Preferred notification method: Phone Email Agent/contractor.. t-J be--- -is)61 k Phone#: )7 tt —Re r, (82-e Mailing Address: Email: Preferred notification method: Phone Email Description of Proposed Work(Additional pages may be attached if necessary): P)2/ 1C1-0- *It 6Lth tS11 1 • Pi AC e d1\ CA elrq d efeteyt.Q An+4✓Vair( ICI .beck ( r �• (j r1_(/fi Dte r r r l sv doges �j3 Jo I € ? , t w i t I'1 ( /f t6 iBack t i- /C /the 2 f r' ....15,R> '•p 0 " (J Signed(Owner or agent):5,1 Date:Ay74AF___ Gf/,� > Owner/contractor/agentgeis 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: /i- ab--)g ✓ Approved _Approved with changes �j Deeniiedd--._ Amount Reason for denial: APPROVED EU Cas a %9 NOV 20 1;'3 I Rcvd by: 64/ YARMUUTI I OLD KING'S HIGHWAY Date Signed:///Z Ofrel 3 Signed: Ci of `'.74.....,,,sp — APPLICATION#: /Se-11/,95/ vs.2017