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Home My WebLink AboutBld-20-000998 .Y Office Use Only dr Permit# Q1 t y y Amount °zwwu"'Er'd Permit expires 180 days from _issue date Bcb-cif EXPRESS BUILDING PERMIT APPLICATI�._____ TOWN OF YARMOUTH Yarmouth Building Department E 1146 Route 28 AUG .`2`3 2019 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 `:,!I P tatrrt ra CONSTRUCTION ADDRESS: `, , 1��.QQYYZac,('‘ Ra - ` 1 ASSESSOR'S INFORMATION: Map: F)(4, 5-0 Parcel: OWNER: Were'-‘ Ro\O iir-NSC)f\ k c-r-4-Pwtilyx P-c' - j'-Og' q-2 I -SD-)-) NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ 4 OC Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman)and' Compensation Insurance: (check one) I am the homeowner 0 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 ��yy (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares I—1 St Replacement windows:# Replacement doors: # Roofing: #of Squares I-1 S%..9)Remove existing* (max.2 layers) Insulation V Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ( .(w►o& #, 0 k s(.,C)S0.\ N1QCk Location ofkacility 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 rev cation of license and for rosecution under M.G.L.Ch.268,Section 1. p Applicant's Signature: icy...' Date: �'-,R3'-/ / Owners Signature(or attachment) Date: '?' — r p�--K i / Approved By: JAL.. Date: — 4%) )S Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 c _= �_ 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 PIease Print Legibly Name (Business/Organization/Individual): Ke-1- Address: ‘ City/State/Zip: '\[o c Y - Q C) -( 7 S—Phone #: ‹? — ° ) --,SC)—?—) 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.] 9. ❑ Demolition 3.11I I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 Ei Building addition 4.❑I 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.El Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.tgRoof repairs These sub-contractors have employees and have workers'comp. insurance.: 14.gOther6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. S�d� 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 certi der the pat nd penalties of perjury that the information provided above is true and correct. Signature: Date: 7-073 ^t/? Phone#: jig _ `j'? 1— SD'77 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#: TOWN OF YARMOUTEPECE 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 AUG 2 2019 Telephone (508)398-2231 Ext. 1292-Fax(508)398-0836 Y Mrt,)IUU I I-1 RECEi NG'S HIGHWAY HISTORIC.DISTRICT COM j r G'SHIGHWAY AUG 'e 3 2019 APPLICATION FOR TOWN CLERK CERTIFICATE OF EXEMPTION SOUTH YARMOUTH, MA 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. Type or print legibly: Address of proposed work: -3 1 F4-'-e.r,f _ie-‘_'e.k. , Map/Lot# 1O( .5-0 Owner(s): 1<C.vrr i jb i r1SOY1 Phone* SC.,5z'-c't'?t—S 07 7 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: .3 t e.w .o \ . Y iwtou.1-4af'E Year built 1q(e9' Email: K 10i\`r S or\cD ivIcrA oy 1 . CC't., Preferred notification method: Phone Email Agent/Contractor. Phone#: Mailing Address: Email: Preferred notification method: Phone Email Description of Proposed Work(Additional pages may be attached if necessary): Woo o\ Ctctk.boat-6 on C'ctfrl.- Shave, bie5e_ Netko &t LL, k Ce..AA( Si-.tA9ieS on. re met tner side_ u."%\-t rim Idoorr-S 4SViuv crs 'rt4- S'4t.nr coo? F/ Signed(Owner or agent): ------) Date: A3/ y > 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: Va_3A 9 /Approved Approved with changes Denied Amount 02e5 Reason for denial: APPROVED Ca CK : J LW, d �� AU( 9 /01a Rcvd by: i4 V Y4\ki,;IUL OLD'KIilC:'S' V, , Date-Signed: F/Z3/Z.C/? Signed: Cd;? .„,eg—*"....—... 13— APPLICATION#: 19 c•O•go V5.2o17