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Home My WebLink AboutBld-20-002692 O�•Y`��4 1 Office Use Only • O - H i; y Amount/0 X L + /D • M7T./EIl CSEj 1 , 4'° ;Permit expires 180 days from '� 1 J CJV 1 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: f I'/-e--e mot Pt g P r 041 Jr?Uvf L ASSESSOR'S INFORMATION: Map: ,//j (, Parcel: ,c--, OWNER: A''1 A k-cr1,-crr- 1196 w1C!ani'olt'a. L' ' 4 4/If; yC NAME PRESENT ADDRESS TEL. # 3 c1 CONTRACTOR: i,y S '/- 6y in P //3v 'hi c�ey,ems r S-G`d ..1i3 �1G3/ /7 NAME % MAILING ADDRESS / TEL.# l NrResidential ❑Commercial Est. Cost of Construction$ //7 02.4•V: Home Improvement Contractor Lic.# C,L (//Ge'6 fl- Construction Supervisor Lic.#Az-424 Get .,04 . Workman's Compensation Insurance: Ccheck one) ❑ I am the homeowner I am the sole proprietor 1 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 Replace ent windows: # Replacement doors: # Roofing: #of Squares 1 -54 ( - Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (1/Replacing like for like Pool fencing *The debris will be disposed of at: 0 v h?IC? ` Gl v rr 5/)C 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: Date: ( ' '" � Owners Signature(or ay chment) Date: Approved By: `_,/-4.,' Date: (1 — '1 9 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes I No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No 0 Yes ❑ No . The Commonwealth of Massachusetts • _u, _ Department of Industrial Accidents gel- 1 Congress Street, Suite 100 Boston, MA 02114-2017 0,A. 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): q c, /j«f 7 g Pch.€s Address: tk, lv' // 'vi'v i)s /Ytnvr.¢11 mti� City/State/Zip: ' 3 a Phone #: ''—'0X- p, Y3 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.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.] 9. ❑ Demolition 3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t _ 10 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.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.i 6.E 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 R1 must also fill out the section below showing their workers'compensation policy information. 4 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. m: 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: P ne 4: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 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 Division of Professional Licensure Board of Building Regulations and Standards ConstructicobSli Msor Specialty i/ CSSL-100697 �` I. Uyires: 02/13/2020 i ROBERT J BYRNES F'+ 70 WALLWIN[�ORNE PLYMOUTH M .R23i0 ' \�`CI' •r Office of Consumer Affairs& Business Regulation- Mass.Gov Page 1 of 2 I I, 1 Mass.gov Office of Consumer Affairs and Business Regulation (OCABR HIC Registration Complaints Registration # 150972 Registrant ROBERT BYRNES Name ROBERT BYRNES Address 70 WALLWIND DRIVE City, State Zip PLYMOUTH, MA 02360 Expiration Date 06/19/2020 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=150972 11/8/2019 Cipiro, Linda From: Richard Herbert <herb1946@hotmail.com> Sent: Friday, November 8, 2019 11:51 AM To: Cipro, Linda Subject: Permit for roof Attention!This email originates outside of the organization.Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Dear Ms. Cipro, This is letter is to notify you that I approve of the issuance of a permit for roof replacement at 1 Freeman Road,Yarmouth Port, Mass. I am the owner of said residence. Sincerely, Richard Herbert Nov. 8, 2019 • 1