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Home My WebLink AboutBld-20-003372 01.• R : uu urn),tce use un • $' • .ram! \C (Permit# O ,1!!0 ''� H !Amount 60 tl,_:\NtTACP ESE -�`,,ragt°.4,"� Permit expires 180 days from ,�� j issue date L1305 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 0012S-n South Yarmouth, MA 02664 11 (508) 398-2231 Ext. 1261 JCONSTRUCTION ADDRESS: D20.- / 2�1-CL4....-I 4Vr. ya.i-p,,.,.-✓r . Pc,f--/ ii.iX ASSESSOR'S INFORMATION: Map: Parcel: /OWNER: J Os 7, L 0 ;1(4.... as 'in t l e(n0.-.,7 AL,.. cam./M,�L P.A. j��/"�"�j NAMME PRESENT ADDRESS / TEL. # a` c, '-d 13- 1,93 CONTRACTOR: NAME MAILING ADDRESS TEL.# ❑Residential 0 Commercial Est. Cost of Construction$ JO E L)W Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) 2 I am the homeowner D. I am the sole proprietor D 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 Replacement windows: # E!a, Replacement doors: # Roofing:' #of Squares ( )Remove existing* (max.2 layers) Insulation v Old Kings Highway/Historic Dist. ( 1,)‘placing like for like Pool fencing *The debris will be disposed of at: 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. Applicant's Signature: l/ Date: �!/ �. /Owners Signature(or,�tt hment) /� Date: /� //�// Q Approved By: Date: !�/�.�� Building Official(or designee)/5 EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: Ei Yes =I No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 2 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,,,5�• 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): J 0 s y,p( n,- //U� Address: / City/State/Zip: �r�• ,,(2 �r 144. Phone #: —a i 3_ l7 5'3 Y . 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.E 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. am a homeowner doing all work myself 9. ❑ Demolition y [No workers'comp. insurance required.]t 4. I am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 Building addition P property. 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 6.❑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.t 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. 1 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 4 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 ce , and tl ai nd penalties of perjury that the information provided above is true and correct. S ianature: Date: /07//`�/� P Phoney''' Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License gr 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 n: .f--'".1''3 'I Z.4:43‘‘,113 R F.--,c-4,,,i,., , ,,„ ,.„,.,,,, 3 Q,Y u a TOWN OF YARMOUTH Y 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 , " Iv Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 OLD ZING'S HIGHWAY HISTORIC DISTRICT PC COMMITErkiGH,,ALAy I APPLICATION FOR TOVvi CL rnK CERTIFICATE OF APPROPRIATENESS SOUTH 'YARh4,,:U 1H Application is hereby ittaa'le or 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,&SUPPLEMEIyTAL INFORMATION. Check All Categories That Apply: Indicate type of Building: Commercial 1, Residential 1) Exterior Building Construction: New Building Addition _Alterations Reroof Garage Shed _Solar Panels Other: t j A.dot)5 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: Address of proposed work: a ro er-a--,A.•1 4 Ye - Map/Lot# A)-). /? Owner(s): OS e t_ .0 r-//0� Phone#: D ..�-'Z C' al_3 /) 99 3 All applications mu t be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: es-1/4‘.4.-7 { Year built: 19 --S.-- Email: Preferred notification method: Phone Email Agent/contractor: Phone#: Mailing Address: Email: Preferred notification method: Phone Email Description of Proposed Work:Re Lei �a. 13 r-v%olc,J _S t -Fh »o f r://tS P `J / ., Signed(Owner or agent): Date: //'‘ > Owner/contractor/ ent is aware that a permit is required from the Building Department.(Check other departments,also.) > If application i pproved,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 subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. For Committee use only: N.,/ Approved Approved with Modifications Denied Rcvd Date: 4. i/1g//9 Reason for Denial: � Amount gQrs1 — , k Cas A Signed: Fj f Rcvd by:. 45Days: I. A+ S9 ' , ,. , IS Date Signed: L //•LO/9' 1 APPLICATION#: i 9 e A 0 9 9