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Home My WebLink AboutBLD-20-004148 , - Office Use Only RECEIVED -ta ple -OrtY , 00•,g. t . ,Amount 50 4 'Permit expires 180 days from '.t4 Ni-r-' •`:4`, A 20711 B LDING DEPARTMENT issue date By: ______ _ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: qg b vol. yOtnotrIM 411/, yd. OM P,4/ gol oow.9.1.5 ASSESSOR'S INFORMATION: Map: Parcel: co57 idA16/1&W274(-1 0/02F OWNER: '"d /lie bin di 077 teilai.Liozra , -N- 1113 34 ffs NAME PRESENT ADDRESS TEL. # CONTRACTOR:J2. 1,, Co.vd4 4 idektoed ittm, Yzogiev•/// &t 0 17g gm 6k19 NAM MAILING ADDRESS ' TEL.4 l‘esidential 0 Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# /( 373b Construction Supervisor Lic.14 U"'" /0/No? Workman's Compensation Insurance: check one) I am the homeowner in am the sole proprietor ._:. 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:# if 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: yakt41741 _6,0 Locallon of Facility I declare under penalties of perj 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 o tion of i license d for prosecution under M.G.L.Ch.268,Section I Applicant's Signature: Date: 12244 2,5 i ?ode Owners Signature(or a ment) Date: Approved By: _.-/".....4.— Date: I Building Official(or designee) EMAIL ADDRESS: Zoning District: _ Historical District: : Yes I No Flood Plain Zone: _ Yes _' No Water Resource l'rotection District: Within 100 ft.of Wetlands: Yes No L._ Ycs -: No The Commonwealth of Massachusetts _,�, - Department of Industrial Accidents gel= 1 Congress Street, Suite 100 4: Boston, MA 02114-2017 5.•'� 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): wrylo Address: A 7 / City/State/Zip: itlir(OGY4 P I Of pate Phone #: qQa Are you an employer?Check the appropriate box: Type of project(required): l.❑Imam a employer with employees(full and/or part-time).* 7. ❑New construction 2. t/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. I am a homeowner all work myself. 9. ❑ Demolition ❑ doing y (No workers'comp. insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on property.mY I will 10 ❑ 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 5.0 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. :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 cer u of,er the pain and penalties of perjury that the information provided above is true and correct. Signature: Date: Jh Phone#: 7g 46/9• 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#: / II' r01o5Y Page# of pages \ ^L .- cs /0(94' / /J )0401ou It ad 6,7C PROPOSAL SUBMITTED TO: acJOB NAME JOB# ADDRESS JOB LOCATION fps Yai4edi M L, • 'ai `"Ali Da�v7� DATE DATE OF PLANS PHONE# y4e#00/4 f FAX# ARCHITECT We hereby submit specifications and estimates for: i(i;itiei -- f-1•4(4414 il —1-144- 1V1 Is Ati."06411S' . ii4t 4,71.7 5 ' , ..__ 'us SO4‘1 Gum a/ '_...._.__ ,,r,'s ` .., ....A/Le e .. „,w_ . .ter ter, `-ri a� /u�la° , � �- r _tl '-1 E - �y� _ _ cu.. __....- yr�k0 ---� �P � ("VC shy/ =- ' ..._...___a,Zel.._ . _...car v a-6s . o., o %%e propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: Am $ LJ -.' eV Dollars with payments to be made as follows:/ }e "/ 3 t i7 /NL i 44- a'- apor lin Any alteration or deviation from above specifications involving extra costs Respectfully will be executed only upon written order,and will become an extra charge submitted •- over and above the estimate. All agreements contingent upon strikes, \accidents,or delays beyond our control. Note—t is proposal may be withdrawn by us if not accepted within days. acceptance of firopogaf The above prices,specifications and conditions are satisfactory and are c 7 hereby accepted. You are authorized to do the work as specified. )'1 , )' ) Payments will be made as outlined above. Signature4 /✓ ' ✓ J 6/4'/" -- Date of Acceptance Wov 411j 4/8 Signature A-NC3819/T-3850 09-11 tag TOWN OF YARMOUTH V/ IVED / 1146 ROUTE 28,SOUTH YARMOUTH, MA 02664-4451 JAN 2 4 2020 r Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 i RM°uTH OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITT Hi HwAy APPLICATION FOR CERTIFICATE OF EXEMPTION Application is hereby made for the 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. Tope or print leaibly: Address of proposed work: 7? Wee/ /4i*rn4 / / yQ noc04 Map/Lot# /ca& i Owrierts): a �eeiry f j PPhone*. Y13 5 t t 'i c2 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: ?"7 / 1 - //K .fir- % .- Alip„w43,i.,Aft Year built: /9$5" Email: Preferred✓✓ notification method: Phone Email Aaent/Contractor: (J04ii `CiptorI.I) Phone#: 178 Z td (tof f Mailing Address:/ ,`„°"'�//S dd `'Ate 1 � ,7Lji) Apt/ kilt ,/ Email:di 4N GGt/t✓d1lfp CDKtirr, ,iA.,,1 eJ.4.i 1.Co Nt Preferred notification method: Phone y Email Description of Proposed Work(Additional Passes may be attached if necessary): N1444 y /+t104 'ltidV1 tots_ /_ �, RECEMvED JAN ?81020 sou TT AR MCLERK OUTH, MA Signed(Owner or agent): /f Date: +Jo71f/�O d > Owner/contractor/agent is 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: V AM—A ci Approved Approved with changes A - . ;' • Amount CO Reason for denial: El) Cash/CK#: J. 9 a 2 7_2020 YARmn Rcvd by: J IDKNGSNITii Date Signed: / 2 7/202 02 4 Signed: J C" 6 l g APPLICATION#: ..24)^' v5.2017 Division of Professional Licensure Board of Building Regulations and Standards ConstatttNui SUpervisor CS-101942 Upires: 08/04/2020 '"; - 14 A int JOHN M CARYAL • 15 NEWFEL141E • L. YARMOUTH wk.,. • -10 6/S's-,-110 Commissioner CAL ..Ore Wommeneoe.eufWey4,167,,..s.sez44,.m/.6 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYRE'LlndMdual before the expiration date. If found return to: • Expiration Office of Consumer Affairs and Business Regulation • -:=.1 07/16/2021 1000 Washington Street -Suite 710 71761',.;.,F4;:Mj JOHN CARVALHWT4 Boston,MA 02118 D/B/A GQN&VRUTiON JOHN CARVALHO.;\ '" 15 NEWFIELD LANE ./:.:7`..., 0,64,04 YARMOUTHPORT,MA 02675 Of Not veil a ure Undersecretary • • • • •