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Home My WebLink AboutBld-20-1827 Y ..y • :- C; Permit# t �� O H 1 Amount • MATTACM,,,,S(� = �`°"°'•"°��d' 1 Permit expires 180 days from : ; :..••' j issue date £u)-a 0-- 1 & EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 201t' South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 //l�l� c-1 CONSTRUCTION ADDRESS: 4).. 0i-C/L pO KO'' 74-tein 0,./1-1.P (f z4 ASSESSOR'S INFORMATION: Map: Parcel:P OWNER: Pt3'V FL O 2/y el pia 0 JENT Hof emytt otoiL, NAME SENT DRESS / TEL. # CONTRACTOR: NAME MAILING ADDRESS STEEL.# ,$'Residential ❑Commercial Est. Cost of Construction$L Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) AI 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 I Replacement windows:# Replacement doors: # Roofing: #of Squares A ( )Remove existing* (max.2 layers) Insulation X Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing r *The debris will be disposed of at: fiekv5J 90 !.'r 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 derjjaLar evocation( li • and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: AP ,� � Date: JO/3// Owners Signa e(or att. h •n AP, _d" Date:/CV/47 Approved By: d �� // Date: /0 /;' / Building Offi ° - _\e EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 'L No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes , No The Commonwealth of Massachusetts f Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 °�M ,�, �•`''� 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):Ogtl((a /46'r-/f'7 Address: 'G Dyck pan- City/State/Zip: (aaArrk e6e j%',V17 p2- / Phone 4-: e: 76 7i,37 Are you an employer?Check the appropriate box: Type of project(required): 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. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 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 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 .❑ROOF repairs These sub-contractors have employees and have workers'comp. insurance.t. 6.❑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. 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 under thz ins and penalties of perjury that the information provided above is true and correct. Signature: ��7 Date: plfi/g _ e Phone#: s p8._mil- l�/S 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#: • ofY TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 r' ; Telephone (508)398-2231 Ext. 1292-Fax(508)398-0836 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE APPLICATION FOR CERTIFICATE OF EXEMPTION 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: 2 OueA por-'O Ff! Map/Lot# Owne s): pap,. motley Phone#:5771''774,-7xl/ All applications must be submittbd by owne or accompanied by letter from owner approving submittal of application. Mailing address: c t3 v CAC GJON 0 6 Year built: Email: ONLMalay 6 torn, NO— Preferred notification method: Phone Email Agent/Contractor: Phone#: Mailing Address: Email: Preferred notification method: Phone /Email Description of Proposed Work(Additional ages may be a ched if necessary): ?e/.e C 14ioc i�rJ s tC i litocu 20 t1 �'�t-1e��A f:{�P �C Sn�4 S ro) , c y tS o Re /co i n Q tn,`\lam, � fN�t ,) ty,•.(Rnyai.J �`�cS ��gPbcara ; coc)r'4-f-1 fted CE D Tc..�; „VA-6- OCT z ZUi j TO'iiN C1.P?K Signed(Owner or agent SOUTH YARMOUTFthaMA/O//f17 > 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: lO-/-i ? y Approved Approved with changes Denied Amount 026 Reason for denial: Cash/CK#: /9 Rcvd by: 16.4 Date Signed:At I Signed: 1 APPLICATION#: V5.2017