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Bld-20-002675 1 01;YAR`r O e Use Only - 0 . 4*l,l- . 0-1 !Amount co, MATTACM CSC I '`° •"°"'cad Permit expires 180 days from i issue date EXPRESS BUILDING PERMIT APPLICAf E € D TOWN OF YARMOUTH Yarmouth Building Department NOV 0 7 2019 1146 Route 28 South Yarmouth, MA 02664 B U H i ; r :T P F N N • (508) 398-2231 Ext. 1261 F, 0.0Q CONSTRUCTION ADDRESS: k, 57 i / iitilE4/V ADA ASSESSOR'S INFORMATION: Map: // 5 9 e- Parcel: OWNER:)c R . _ f`(iCf 1 M -,iimetigVoZ./� �f iXJJ/L)I) PRESENT S"' Tn. 4 -CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est. Cost of Construction$ _ /i7rb V Home Improvement Contractor Lic.( Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I 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:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing L•The debris will be disposed of at: �� 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 attachment) . � ,,/5 _C.- Date: //. 1.. /Y. Approved By: ,4_ / Date: — 15 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes C No Flood Plain Zone: C Yes Ei No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts r . Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 °�M..s,,,$. www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 5-) b l Address: City/State/Zip: Phone #: Are you an employer?Check the ppropriate 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 a capacity.[No workers'comp. insurance required.] 3 I am a homeowner doing all work myself. 9. ❑ Demolition y [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 11.0 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.❑ROOF repairs These sub-contractors have employees and have workers'comp. insurance.i 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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-contactors 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 under the.p ins d penalties of perjury that the information provided above is true and correct. SiQnatur Date: Phone#: Cl/ Y—646 6 /64 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#: iiii . 1 ,r `.°�YgR416 TOWN OF YARMOUTH ' r I ' ;,?;...;:.t.4 ,3 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 6 1019 �.,. Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836 L......._________________Ji0tDi,rririiiquu OLD-KING'S HIGHWAY HISTORIC DISTRICT COMMITTEEHWA NO v 0 APPLICATION FOR SOS r©✓,,_c1.r=,4, CERTIFICATE OF EXEMPTION • I\ `,,"1-El, pviA 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: ,�1 _ I D Address of proposed work: .5/ H-ir rO cJ JB� .bc t cn13f 6 sc-i- Map/Lot# //`S, 9 2 Owner(s): Aare," krae( be._(-- Phone#: gyp/9,t y s-/O/t) All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: S a—'—rte.— Year built: /92S Email: pm I ,SkR I2 gmo;\.1 m Preferred notification method: Phone Email Agent/Contractor: Phone#: Mailing Address: Email: 0/41. flu ./(viiii Preferred notification method: Phone V Email Description of Proposed 1110 k(Additional pages may be attached if necessary): coed clapboard -Cron+ a se W:-1-FN sam9-.6�a.:'-F4d ��'r�-�,1 � Re�la.c;.� �o ap b hou 0 ogefla.ca nq pa e—vi-ed 41-�1tz/145Oek 'e) it,rI6 c s;4e v slr�trllss - 13G s :,ned i ra...I,CRerna; 1 fa�.,.4-ed sk es cep I aced czA- at_ I r d.ac.-�,) Signed(Owner or agent It� Date: /•6 R > 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: 11/09 /Approved Approved with changes Denied Amount °AO Reason for denial: APPROVED Cash/CK#: A / NOV 7 2019 Rcvd by: V YARMOUTH OLD KING'S HIGHWAY 7? 4--- Date Signed: ///7 e7 7 Signed: fS ,,,,k,.a,, APPLICATION#: 19",47/03 V5.2017