The URL can be used to link to this page

Home My WebLink AboutBld-20-001664 Office Use Only pF• RR , :. .4 it#�D- 60 / O '-i//g C; .Amount .,ATTAIN Cu I„ -_�t^.,:..0,i d' �;'Permit expires 180 days from #:;=::.:. issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: a C `e i4 le 13p..6eD M Rd s L. (/Xl R /1l D '(t 11 ASSESSOR'S INFORMATION: Map: Parcel: -/ OWNER: .$c DTI IP �� /1� -T7'�_ � 6kl�' RL'DK c�. ' �!/7-/I� �� i ] NAME PRESENT ADDRESS TEL. # d-- 5-''-34y--3Di-y CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ ›,5- 000. i Home Improvement Contractor Lic.# Construction Supervisor Lic.# t Workman's Compensation Insurance: (check one) , AI am the homeowner ❑ I am the sole proprietor 0 I have Worker's Compensation Insurance .1t ' `—., u 6 Insurance Company Name: Worker's Comp.Policy# -:.3160 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /6- Replacement windows:# Replacement doors: # 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: yA/�vrt p 1,t 1"'6 L j+,{J°C� f j L L 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. .5 Applicant's Signature: Date: 7 —aZ -J ? Owners Signature(or attachment) C/ Date: 7,-- , I- Approved By: - Date: 9: C/9 Build' ffi ' (or esignee) EN ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts y i? Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 • • 5.•°'sc www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): Address: G - City/State/Zip: (V yA I U 1-(i Phone #: )'D f•— '3 — 3ij I Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑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.gI 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 Eli Building addition 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. These sub-contractors have employees and have workers'comp. insurance. 13. Roof repairs 6.❑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'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. TContractors 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: Date: 9--) 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 4: Doc: 1 ,3307012 09-18-2017 3=29 Ctft-214O72 BARNSTABLE LAND COURT REGISTRY QUITCLAIM DEED I, ROBERT OUELLETTE, being married, of 18 Clear Brook Road, West Yarmouth, MA 02673 For CONSIDERATION PAID of ONE DOLLAR($1.00) GRANT to ROBERT H. OUELLETTE, JANE S.OUELLETTE,and SCOTT R.OUELLETTE as JOINT TENANTS, of 18&22 Clear Brook Road,West Yarmouth, MA 02673 With QUITCLAIM COVENANTS Land in Yarmouth, Barnstable County, MA, as follows: Being shown as LOT 36 as located on subdivision plan 30561B (Sheet 2)filed in Land Court Registration Office at Boston,a copy of which is filed in Barnstable County Registry of Deeds in Land Registration Book 265,Page 98 with Certificate of Title No. 33968. Said premises are conveyed subject to and with the benefit of easements,restrictions and reservations of record, if any, insofar as the same are now in force and applicable. Property address: 22 Clear Brook Road,West Yarmouth,MA 02673 For title see Certificate of Title#95171 at Barnstable Registry of Deeds,Land Court. IN WITNESS WHEREOF, We herein set our hands and seal this September 13, 2017 !t g. 04 . / i/1/ , Robert Ouellette OF Jane S. Ouellette Commonwealth of MA Barnstable,ss On this 13th day of September,2017, before me,the undersigned Notary Public,personally appeared, Robert Ouellette and proved through satisfactory evidence of identification,which was Massachusetts Driver's License,and acknowledged to me that the contents of the document are truthful and accurate to the best of his knowledge and belief. Acknowledged this signing as his free act and deed. o • Public 0 A ' 'T J. OWENS CO :J,`,b I) r Notary Public 3�•a� ' COMMONWEALTH of MAssACHusETrS / My Commission Expires March 29, 2024 J f't ( C BARNSTABLE REGISTRY OF DEEDS John F. Meade, Register