The URL can be used to link to this page

Home My WebLink AboutBld-20-2706 off ice Use Only $O R`�o`, � s5C. 1Pemfl26a % ,�, 1 NOV 08 2019 ' $ 'Amount MATTACM UI _ °`°"•°••°�°"9 d'• 6_ Permit expires 180 days from issue date BWI_v r,,, ut 1 AN I FEN T e By EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 p 8 2019 South Yarmouth, MA 02664 Nw (508) 398-2231 Ext. 1261 'I '� ARTM 0. �� CONSTRUCTION ADDRESS: d-q lqe_Se Co., wy ASSESSOR'S INFORMATION: Map: Parcel:� OWNER: t .�1n) Red 1(.i �� t-leA RvvnJ f/i—La•. o 7 3 (/7- e7?— q9 i.� NAME T PRE T ADDSS TEL. # CONTRACTOR: bu N 611 c J'' po &)Q BO' er-r 1)4 S-1 5-11—7- X0,6 NAME-S'.4.h c'IQ S'Mu t T, d MAILING ADDRESS ) TEL.# VICsidential ❑Commercial Est. Cost of Construction$ 3 v,OUO .00 Home Improvement Contractor Lic.# Construction Supervisor Lic.# CS"—O°6O.5S Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor i'I have Worker's Compensation Insurance Insurance Company Name: CAS 7`tA4.) init%)'1.4CC_ 61.4 d e Worker's Comp.Policy# JJCA q OcLf 7 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove . Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares LK ( `� )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: E rk-- COST ,S\e S'-e.A. 'j 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.P.."..----- Applicant's Signature: Date: '/ q( / ::::::;t ure(or attachment) Date: 'g•i J� e C 4... ..,2( /.�. *� Date: I‘ —p —)S Buildinb icial(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ,U No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes , No The Commonwealth of Massachusetts 7 i-k )ifiDepartment oflndustrialAccidents k ) 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): lCj7 `DA.I.Srµ.vGno Address: Pb ( vo-1 City/State/Zip: 6-resvri4, 01 4 O L- ( Phone #: S"Fr `?3'?—CS‘ Are you an employer?Check the appropriate box: Type of project(required): 1.11 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.] 3.0 I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 9. ❑ Demolition 10 ❑ Building addition 4.11 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.❑Plumbing repairs or additions 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.+ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§I(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: ��3'l ) S J /ZAN GP 6 w oe Policy#or Self-ins. Lic. m: UU CA q d 1-6- `7 Expiration Date: i o f/4 /j Job Site Address: a y J4ec,C_ a 0 City/State/Zip: $ 11 0 2473 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: // 8/ 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#: Massachusetts Department of Environmental Protection 100316563R2 BWP AQ 04 (ANF-001) �.. Asbestos Project # Project Revision Notification � p Project Revision r Project Cancellation A. Asbestos Abatement Description 1.Facility Location: RESIDENTIAL 24 HEDGE ROW Instructions 1.All a.Name of Facility b.Street Address sections of this form YARMOUTH must be completed in MA 02763 6178729933 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification MARTY REILLY OVVNER requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: ROOF Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2.Blanket Permit Project Approval,if applicable: CMR 6.12 Approval ID# 3.Non-Traditional Asbestos Abatement Work Practice Approval, MassDEP Use Only if applicable: Approval ID# Date Received 10/7/2019 11/15/2019 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 8AM-4PM NO HOURS c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday B. Other Project Revisions: Note:Temporary storage of Asbestos containing waste material is only allowed at the place of business of a DLS licensed Asbestos contractor or a transfer station that is permitted by MassDEP and operated in compliance with Solid Waste Regulations 310 CMR 19.000 Note:Contractor must sign this form for DLS ,N, . Massachusetts Department of Environmental Protection 100316563 BWP AQ 04 (ANF-001) Asbestos Project # :1-T, Asbestos Notification Form ✓ Project Revision ✓ Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): ✓ a.Glove Bag r b.Encapsulation r c. Enclosure r d. Disposal Only r e.Cleanup ✓ f.Full Containment ri g. Other-Please Specify: BtvP 13. Job is being conducted: r a. Indoors F. b. Outdoors 14 a. Total amount of each type of asbestos Containing materials(ACM)to be removed, enclosed,or encapsulated: 1600 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation e.Transite Shingles 1600 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h. Cloths,Woven Fabrics i. Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15. Describe the decontamination system(s)to be used: IN ACCORDANCE WITH ALL STATE,FEDERAL AND LOCAL REGULATIONS 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): DOUBLE 6ML POLY BAGS 17. For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this r a.Yes ri b.No project? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection 100316563 BWP AQ 04 (ANF-001) Asbestos Project# L71111 Asbestos Notification Form r Project Revision r Project Cancellation B. Facility Description 1.Current or prior use of facility: RESIDENTIAL 2.Is the facility owner-occupied residential with 4 units or less? r a.Yes r b.No 3 MARTY REILLY 24 HEDGE ROW a.Facility Owner Name b.Address YARMOUTH MA 02673 6178729933 c.City/Town d.State e.Zip Code f.Telephone 4.TOM MCCOOG 312 HILLMAN ST a.Name of Facility Owner's On-Site Manager b.Address NEW BEDFORD MA 02740 5088897865 c.City/Town d.State e.Zip Code f.Telephone 5 FRANKLIN ANALYTICAL SERVICES 401 DELANO RD a.Name of General Contractor b.Address MARION MA 02738 5087483156 c.City/Town d.State e.Zip Code f.Telephone TRAVELERS g.Contractor's Worker's Compensation Insurer 0703N229 7/1/2020 h.Policy# i.Expiration Date(MM/DD/YYYY) 4579 2 6.What is the size of this facility? a.Square Feet b.#of Floors Note:Temporary C. Asbestos Transportation & Disposal storage of Asbestos C containing waste 1. Transporter of asbestos-containing waste material from site of generation: material is only allowed at the place r a.Directly to Landfill or r b.To Temporary Storage Location/Transfer Station of business of a DLS licensed Asbestos contractor or a transfer FRANKLIN ANALYTICAL SERVICES 401 DELANO RD station that is c.Name of Transporter d.Address permitted by MassDEP and MARION MA 02738 5087483156 operated in e.City/Town f.State g.Zip Code h.Telephone compliance with Solid Waste Regulations 310 CMR 19.000 2. If a temporary storage location/transfer station is used,list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: EAST COAST SYSTEMS 6 CEDAR ST a.Name of Transporter b.Address COTUIT MA 02635 5084280006 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 L 11111111"11111 Massachusetts Department of Environmental Protection 100316563 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r Project Revision r Project Cancellation C.Asbestos Transportation&Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: EAST COAST SYSTEMS 6 CEDAR ST a.Temporary Storage Location Name b.Address COTUIT MA 02635 5084280006 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISE INC a.Final Disposal Site Name b.Final Disposal Site Owner Name 8955 MINERVA RD c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone Note:Contractor must sign this form for DLS notification purposes D. Certification AMY FRANKLIN AMY FRANKLIN "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PRESDE T 9/24/2019 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) all attachments and that, based 5087483156 FRANKLIN ANALYTICAL on my inquiry of those 5.Telephone 6.Representing individuals immediately 401 DELANO RD MARION responsible for obtaining the 7.Address 8.City/Town information, I believe that the MA 02738 information is true,accurate, and complete. I am aware that there 9.State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment. The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Paee 4 of 4 Office of Consumer Affairs& Business Regulation- Mass.Gov Page 1 of 2 Mass gov Office of Consumer Affairs and Business Regulation (OCABR HIC Registration Complaints Registration # 158212 Registrant DONALD T. BLISS JR Name DONALD BLISS Address 129 PADDOCK CIR City, State Zip MASHPEE, MA 02649 Expiration Date 01/04/2020 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search Site Policies Contact Us https://services.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=158212 11/8/2019