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Home My WebLink AboutBld-20-001458 .Y.9R Office Use Only 41 Permit# '`yam �Amount � V' 4' NATT N CS( , Permit expires 180 days from ;i '-` ssue date EXPRESS BUILDING PERMIT APPLICATIONS fl TOWN OF YARMOUTH Yarmouth Building Department SH) 1 h 2019 1146Route28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: J 7 ,a rm D a- L/--poir Z ASSESSOR'S INFORMATION: / ,, Mahon Map: /3i Parcel: /' 62 OWNER:LLL/S 1 on E 53 tot_/6T /4', ,Ln • 6-O8`" 4( - 00 S Z NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ 60 gi 0 b V Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman' ompensation Insurance: (check one) aVi 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 Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 3 1 Replacement windows:# 6 Replacement doors: # c2 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation ✓ Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: V Q' j t 10 1)Q/LK!S J //i A 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 o vocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: CI i l 1p I cl Owners Signature(or attachment) ,, Date: q ', )1l Ct Approved By: J �(jyr. Date: ek—16 -1 PP Building Official(or designee) EMAIL ADDRESS: Zoning District Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts `lid►= Department oflndustrialAccidents A= 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): Z_Q u j S /72al Address: 3 /J c- ,Ln Ci /State/Zi 02b7-S tY P: IYIDLr� O/ /W Phone #: 5d$ - 7 04 f5 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]1. 9. El Demolition 10 ❑ Building addition 4. am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ 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. 1. .❑ROOF repairs These sub-contractors have employees and have workers'comp.insurance.i 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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. 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi; ,er the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: I %Q 19 Phone#: 6®5---}4 i0-00 5s Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ° 7, TOWN OF YARMOUTH R D si RECEIVED r$ 1146 ROUTE 28,SOUTH YARMOUTH, MA 02664-4451 AUG 1 6 4 ,} I Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 SEN 10 PAD KING'S HIGHWAY HISTORIC DISTRICT COMM Mvs 'wAY TOWN CLERK APPLICATION FOR SOUTH YARMOUTH. MA CERTIFICATE OF APPROPRIATENESS Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as amended,for proposed work as described below&on plans, drawings, photographs, &other supplemental info accompanying this application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S), ELEVATIONS,PHOTOS,&SUPPLEMENTAL INFORMATION. Check All Categories That Apply: Indicate type of Building: Commercial \"Residential 1) Exterior Building Construction: New Building Addition Alterations Reroof Garage Shed Solar Panels Other: 2) Exterior Painting: ✓Siding Shutters Doors ✓Trim Other: 3)Signs/Billboards: New Sign Change to Existing Sign 4) Miscellaneous Structures: Fence Wall Flagpole Pool Other: Please type or print legibly: 1 Address of proposed work: 53 ' 'W -e /el" 4-41- a Map/Lot# rsg 4 f Owner(s): kO a_/S £ kf r6L- in[ a_/ _on_ Phone#: 6-0 S —4-4(o a 2— All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address:53 to/us i ter Lit , lila I7/7011-+1LpOi � Year built: /7 8 Email: /27 tt/20/z e1. ,L//@y alt O° + 2 0m Preferred notification method: ✓ Phone Email Agent/contractor: ,LOtL IS I77 a-./ O Phone#: S l rre e- Mailing Address: Si 4L4r7,e Email: Sr ,fl'e Preferred notification method: ✓ Phone Email Description of Proposed Work: '/zapla_ee a_// waLSv4v'.s1 A..oase 0-4d ja-r-a-je r,-u'`fk- b /Qtx-- Anderson 1/OO Sec S. `�/t k- 'epiat�2 cz.// S/o%ny , lE�dar� s'�-in�9/tl an c! e la�abaard, /t_Cr,CSP a2d i arAge • Rep/ate 5�idpr s � xl-/I-di-er�son � -S'erie c pa-1iO doors j 6%ae� . — pQ; 71- A siding i2 ve re Awl/er-, /, et-ti'- 4r„IVL w A-t: - - Signed(Owner or agent): d-u� Date: e. i I ( i ei > Owner/contractor/agent is aware that a permit is required from the Building Department.(Check other departments,also.) > If application is approved,approval is subject to a 10-day appeal period required by the Act. > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. > All new construction will be subjectttto inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. For Committee use only: '" Approved Approved with Modifications Denied Rcvd Date: �. /(0, 19 Reason for Denial: Amount Al b Signed: e �"A ,, Rcvd by:lip Q c , , , . 45 Days: 9.36,19 Date Signed: - 2 0/ �1� � -- 1 APPLICATION#: m