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Home My WebLink AboutBld-20-003300 .Y9R %,��,y 4 • 4170 ea3 0 . , 1,' . H Amount MAT TA°M f3[' 'Permit expires 180 days from l issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department i 1146 Route 28 �y� South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 Ah.s Mae I ASSESSOR'S INFORMATION: y� Map: Parcel: q OWNER: K-4 tl er CO",O �l -tvlC l`(3 k y4ti nty, /�� (5 7 S q.2rk� NAME PRESENT ADD SS �// n TEL. # CONTRACTOR: are. A, Fj0 G�hGeiR t� ra f/�' Iha/r 'Sp'1 t , /I/r'� �J� '07 NAME MAILING ADDRESS du,{E TEL.# ❑Residential <Commercial Est.Cost of Construction$ 675 Z Home Improvement Contractor Lic.# Ic S 13(o Construction Supervisor Lic.# C 51a77c,y Workman's Compensation Insurance: (check one) I am the homeowner 0 I am the sole proprietor )(I have Worker's Compensation Insurance Insurance Company Name: L rev w— .:JLKt u,-a4144_ Worker's Comp.Policy# 2.3 6 7 y etnc 1 vrier,q c_ , WORK TO BE PERFORMED �par�ti'�to►lS Tent Duration • (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 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: 1 < k/LPS t4,46. 4 to I !'�/ f/i ur (J/uGJ. rt f A�c a Locat o-n 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: /2/rl`/y Owners Signature(or attachment) de OP tr cie . Date: Approved By: ✓ Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes II No The Commonwealth of Massachusetts • =Wru� Department of Industrial Accidents ="/11= 1 Congress Street, Suite 100 ff-- = E`=_ Boston, MA 02114-2017 e. 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): J- A►aely .o-. Address: r v C,ze,-lam.,eny:/ & ,i City/State/Zip: s fridti e?4 026fe Phone #: (-5Z ) (991 —07 d-8 Are you an employer?Check the appropriate box: Type of project(required): I.E I am a employer with 2 employees(full and/or part-time).* 7. ❑New construction ?.❑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. k Demolition ❑ doing y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. I will I O ❑ 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.❑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.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#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: I eC,N.utr-d Z ri,,a„r.e Policy#or Self-ins. Lic. 4: Z-5-6', V Expiration Date: 409120 Job Site Address: 30 .i-e,) 1.61({4 /2-- City/State/Zip:k. I yarouiA diAl 4 6?,3 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: 7/9' ate: � Phone#: e ,;.,9-1 -0.7 . 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 4: Cipro, Linda From: Jessica Sylver <jessica@jkellerco.com> Sent: Tuesday, December 10, 2019 9:05 AM To: Cipro, Linda Cc: 'Sandra Marquis' Subject: 30 Ansel Hallet 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. Good Morning Linda, Please accept this email as approval for Jeremy Anderson to pull a demo permit for 30 Ansel Hallet Road. Jeremy Anderson is authorized by 30 AH LLC to work on the property. Please let me know if you need anything else. Thanks, Jessica Jessica Sylver Keller Company 1436 lyannough Road Hyannis, MA 02601 508-375-9300 1 VDivision of Professional Licensure Board of Building Regulations and Standards Construct%11AiSpirvisor CS-1'07704 Orpires: 10/13/2021 JEREMY AN[*RS• 1. 80 CRANBERRY e ‘ -t1 .. D; MARSTONS M)LL f i Commissioner/ 4---- / d Oam... • •