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Home My WebLink AboutBLD-19-3941 g-vluw u • se tally:C £ Cg Amotmt — V_" • T. k?permit expires 180 days from f issue date BCD—Iq-co3G1/411 RECEIVE f •• EXPRESS BUILDING PERMIT APPLICAT - 41 , TOWN OF YARMOUTH � MIT n3 Yarmouth Building Department nun I - - ! 1146 Route 28 Run ;lief-raw i 1 South Yarmouth,MA 02664 dr L E�`s.) '�"_t (508)398-2231 Ext. 1261 ^ _ M CONSTRUCTION ADDRESS: 4 1 Ce-t 1 %QUT� ltd. 1 • torTS ASSESSOR'S INFORMATION: • Map: 114 Parcel: SC, OWNER: &QA '11&jltlt'., 41 LAii 1.c. 34 ,Y M� snacc 5cS-irro-Cc2A3 NAME ,,—`- PRESENT ADDRESS TEL # coNTRACTOlf ' 'A' C AcMec�- NAME MAILING ADDRESS TEL# thiesidential 0 Commercial Est Cost of Construction$ 5i O- J.--- Home Home Improvement Contractor Lle..# Construction Supervisor Lie.# Worlunan .compensation Insurance: (check one) ' 6'�am the homeowners 0 IIaamm the sole proprietor 0 I have Worker's Compensation insurance Insurance Company Name:Sl) �"YT Worker's Comp.Policy# Clejo,e ht€AncQ CO. WORK TO BE PERFORMED Tent 0 Duration JACO& (Fire Retardant Certificate attached?) Wood Stove /a0 Y`a�6 Siding: #of Squares Replacement windows:# Replacement doors: # 3 ' R# Roo g: #of Squares ( )Remove existing*(max.2 layers), Insulationlee- f) 'Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing ' 'The debris will be disposed of it l'1QQrflexint` L as +auA L * 2, 1D : eeW� r 1'1—Scot-air c , Loa ton of Facility ? S)c lot�af p '1 +CeS I declare under penalties of pajmy that the statement herein contained an true and correct to the best of my knowledge �eet I understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under MGL Ch.268,Section 1. Applicant's Signature: ,„ - Date: Owners Signature(or ahment) (>k 14— ,111----�� Date: I x ? ' 1 Approved By S7— Az.-+C/� / — 3` ",Q d_ng Official(or designee) EMAIL ADDRESS: L+0.1 lie sue 9 5% Cli Sf/0,(m,cc, A L Zoning District - Historical District 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No ' v Water Resource Protection District Within 100 R of Wetlands: ' 0 Yes 0 No 0 Yes 0 No Project Overview Work Location: 41 Randolph Road, Yarmouth Port MA 02672 Map: 114 Parcel: 36 Property Owner: Sandra P. Taylor, 41 Randolph Road, Yarmouth MA, 508-776-6203, Calliesue9596@yahoo.com Work Description: Kitchen is approximately 45 years old and in need of an entire update including: o One (1) 6' Slider removal and direct 6' replacement. Two (2) 30x80" Garage- to-Interior Firedoor removal and direct replacements. Work to be performed by Home Depot Installation Team with a specific Express Building Permit in place. o Removal existing Kitchen Cabinets, Appliances, Flooring, outside wall sheetrock and insulation, and other possible Kitchen wall sheetrock. Demo Work to be performed by Home Owner with appropriate/required Tenting. Demo materials will be taken to Yarmouth's Disposal area. Demo work to be covered under an overall Express Building Permit by Homeowner. o Update of Kitchen Electrical Circuits with appropriate ARC-fault breakers and GFI electrical code requirements. Electrical work to be performed by a Licensed Electrician with a specific Express Building Permit in place. o Update of all Kitchen Plumbing and Heating systems to be performed by a Licensed Plumber with a specific Express Building Permit in place. o Installation of new R19 (or greater) Insulation within outside wall. o Installation of new Sheetrock. o Paint all Walls and Ceiling. o Installation of new Kitchen Cabinets with updated units. o Installation of new Flooring (wood or porcelain). o Installation of new Appliances. Home Owner: reS1411 ` 3227-- " 27-- Date: 1 #) 47 ` a The Commonwealth of Massadhusetts t•=— _ l Department oflndustriaiAccidents • l_ I Congress Street,Suite 100 zBoston,MA 02114-2017 tl` .= 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/organizationnndividual): oSe. 2.A lel Lf-te-- Address: 41 PschiAct.soli Knca c'521dT5 City/State/Zip:raymou-Ort ra12T MA Phone#: 52x3- It1Co - Cel203 Are you an employer?Check the appropriate box: Type of construction project(required): 1.❑1 am a employer with employees(fill and/or pact-time).• 7. 2,w2.01 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself[No workers'comp.insurance required]t 9. LvJ Demolition ��((yyt�;�E 10 Q Byilding addition 4.�a homeowner and will be hiring contractors to eondutcCaH•work on my property. I will rur�L ensure that ell contractors either have workers'compensation insurance or are sole 11. lecn'ical repairs or additions proprietors with no employees. 12. umbing repairs or additions 5.EI I am a general contractor and I have hied the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contactors have employees and have workers'comp.insurance) ir 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.0 OtherI Cut Coto Y 152,§1(4),and we have no employees.[No workers'camp.insurance required.] Rft0e.+uySt:e vintAr a X02 s 62 •Any applicant that checks box#1 must also fill out the section below showing theirworkers'compensation policy information. t Homeowners who submit this affidavit indicating dry are doing all work and then hire outside contemn must submit a new affidavit indicating such. tContracmn 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. - •- - •••. _ _ . ...., - Below Ly the policy and job site information. .. _ . . Insurance Company Name:S[.t}I Per / deg aa.T. nn•tee.Co Policy#or Self-ins.Lie.#: ALO( —Car r1 ICS-01O1 Expiration Date: Job Site Address:4 i 24OntlektitD City/State/Zip a16ahe mtc; 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 penolnot o er' ry that the information provided above is true and correct Signature: • Date: 1 • 2 .19 Phone# 1*16-62.03 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.Cityfl'own Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: