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EXPRESS BUILDING PERMIT APPLICATsION e ; r_
TOWN OF YARMOUTH
Yarmouth Building Department i
1146 Route 28t1U '
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261 � Y
CONSTRUCTION ADDRESS: ."/ cod.
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: —fa/ted S vN/- 3 A
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: (&anc4 d g- Po 6c V 2a I S. D.0nn.s r»►i 6-0.8)-73 -yo 84-
NAME MAILING ADDRESS TEL#
10 Residential ❑Commercial Est.Cost of Construction$ SZIZTTI>
Home Improvement Contractor Lic.# 19'i31( Construction Supervisor Lie.# I t'�i°2-
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor V I have Worker's Compensation Insurance
Insurance Company Name: /TA/irl n?vftteL Worker's Comp.Policy# 3�s�
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares // Replacement windows:# Replacement doors: # I
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: %rm n ✓
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 MG.L.Ch.268,Section 1.
Applicant's Signature: i Date: 1//f/2„4` 47
Owners Signature(or attachment) ljnigllgllIllre Date: (t I r at,
Approved By: Date: "I 1
Building Official(., designee) EMAIL ADDRESS:
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No Yes No
The Commonwealth of Massachusetts
1'--, �—!/ Department of Industrial Accidents
=iei= = 1 Congress Street,Suite 100
5f�1�54 Boston,MA 02114-2017
''.:%„r .;B www mass.govfdia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lesibly
Name (Business/Organization/Individual): L IG'-3 o 4 /cC �,, j. �.,,, -j-',•-.:ci-,s (-1-C
Address: ?c? 60 K Zc_c /
City/State/Zip: 5. p-erw,:r ill A ozze tt-o Phone#: (Sob) ;73?—470 8
Ar
e you as employer?Check the appropriate box: Type of project(required):
nI I am a employer with I employees(full and/or part-time).* 7. ElNew construction
21 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.0 I am a homeowner doing all work myself[No workers'coup.insurance required.]t
10 0 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.
12.0 Plumbing repairs or additions
5.0 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.: U.Q Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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'coon 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 proving workers'compensation insurmece for my employees. Below is the policy and job site
information.
Insurance Company Name: IHJ i u-i,o✓j
Policy#or Self-ins.Lic.#: '3'3 4,5S Expiration Date: 3 % /Z/ 2_0 2,t9
Job Site Address: 3 4- 1 e-c c t Atit.e City/Staterzip:`jL/tyw✓qL for4 i 11A out 5'
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 corral
Signature: Date: I i/ ( /Zo 1
Phone#: (C---, ) 3 7 —`-‘4)8 Y"
4 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#:
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A�COi� DATE(rrrrioorrrrY)
R " CERTIFICATE OF LIABILITY INSURANCE 10/08/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 03134-001 �ieCT Branch 3134-1
AAA Insurance Agency Inc 1748 io.E...(800)222-4242 j W.No
110 Royal Little Dr
Y ASg SHollandNaaanortheast.con
Providence,RI 02904 —
INSURER(31 AFFORDING COVERAGE NAIC 4
j)NSA. A.LM.Mutual Insurance Company 33758
INSURED INSURER B
LR3 BUILDING & FINE FINISHES LLC
INSURER C:
17 ASHRINS DRIVE
INSURHRD:
SOUTH DENNIS, DOA. 02660
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WINCH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
IN EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE WA IN POLICY NUMBER i �j y1 Y y_ ___.---- LIMITS
GENERAL LIABILITY I EACH OCCURRENCE $ — — -
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
I PREMISES(Ea occurrence)
CLAIMS-MADE OCCUR I MED EXP(Any one person) $
PERSONAL&ADV INJURY $
I GENERAL AGGREGATE •$
GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMPOP AGG •$
POLICY -- T LOC
•AUTOMOBILE LIABILITY t COMBINED SINGLE UMIT I
I$
(Ea accident)
ANY AUTO •
I BODILY INJURY(Per person) $
ALL OWNED 1---i SCHEDULED
AUTOS BODILY INJURY(Per accident)_$
I,I !AUTOS NON-OMIED . I PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident]
$
UMBRELLA LIAB OCCUR ! I EACH OCCURRENCE $
EXCESS LIAB CLAIMS MADE 4 I AGGREGATE s
DED i RETENTION $ I $
WORKERS COENSATION X TORY HATS OER
A }OFFIC PAARB�IL�IER/E)(ECUTIVE Y 1 N i E L.EACH ACCIDENT $ 100,000.00
(lAandatory 1MBER EXCLUDED? i N� N I A VWC-100�0236ST-2019A y 3/1212018 3112/2020 ; 100,000.00
E.L.DISEASE-EA EMPLOYEE $
If E D �ION g O� rrPERATIONS below E.L.DISEASE-POLICY LIMIT Si 600,000.00
i •
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
LEONARD RENO is covered by the workers compensation policy.
CERTIFICATE HOLDER CANCELLATION
Town Of Barnstable
Attention:Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Hyannis,MA 02801 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZE)REPRESENTATIVE
____,.r --�-
®1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD
R RED°
TOWN OF YARMOUTH �� — 2019
RECEIVED 1146 ROUTE 28,SOUTH YARMOUTH,MA 02664-4451
_ Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836
YHi-<iviUU)IH
JUL 2 6 ZOLD KING'S HIGHWAY HISTORIC DISTRICT COM IT ENG'S HIGHWAY
TOWN CLERK APPLICATION FOR
SOUTH YARMOUTH, MA CERTIFICATE OF APPROPRIATENESS
Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as
amended,for proposed work as described below&on plans,drawings, photographs, &other supplemental info accompanying this
application. PLEASE SUBMIT 4 Copies OF SPEC SHEET(S),ELEVATIONS, PHOTOS,&SUPPLEMENTAL INFORMATION.
Check All Categories That Apply: Indicate type of Building: Commercial X Residential
1)Exterior Building Construction: New Building Addition X Alterations Reroof Garage
Shed Solar Panels Other:
2)Exterior Painting: X Siding Shutters X Doors X Trim Other:
3)Signs/Billboards: New Sign Change to Existing Sign
4)Miscellaneous Structures: Fence Wall Flagpole Pool Other:
Please type or print legibly:
Address of proposed work: 37 Railroad Ave. Yarmouth Port Map/Lot# 112 . 18
Jeffrey and Maureen Stewart 508-962-9768
Owner(s): Phone#:
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 37 Railroad Ave. , Yarmouth Port, Ma 02675 Year built:
Unknown /8005
Email: ii
7 rstew3@Charter.net Prefed notification method: Phone X Email
1 Agent/contractor: Phone#:
Mailing Address: ' _
Email: Preferred notification method: Phone Email
Description of Proposed Work: Attached Document
Signed(Owner or agent): Date: 6/24/I 9
> Owner/contractor/agent is aware t t a permit is required from the Building Department.(Check other departments,also.)
➢ If application is approved,approval is subject to a 10-day appeal period required by the Act.
➢ This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
➢ All new construction will be subjectto inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections.
For Committee use only: %//Approved Approved with Modifications Denied
Rcvd Date: 2 a. /J0
Reason for Denial: A P PD
Amount 4/0
Cash/ 1O il& -&�'1� ,,n� �/� ��� 2 -
Signed: � ;YI/�/-U.,�,�(� !1�
Rcvd by: ISA/ Y41<tvtUUTf
45 Days: Or, 14,19 -64 T 0/t° , E , , + ;njr_ c yiC►a1_;r:
Date Signed: 07 09 9
1 APPLICATION#: 1 / 0 5 7
6
RECLINED'
JUL - 2 2019
Town of Yarmouth YHKNIUU[H
OLD KING'S HIGHWAY
Old King's Highway Historic District Committee
Certificate of Appropriateness
37 Railroad Ave.
Yarmouth Port, Ma.
02675
1. Exterior Painting
a. All trim to be painted white '
2
b. Front door to be painted Hale Navy Blue (Benjamin Moore HC-154)
YA
2. Windows and Siding
� LS'!iGFiWAY
a. Replace 7 windows(1 front, 2 on each side, 2 back)
i. Simulated Divided Lite Windows RECEIVED
ii. Same size as current windows
iii. White exterior
iv. Colonial grill (6 panes) JUL 2 6 2019
i�earivni'rid ► Cabe' TOWN CLERK
1
ptaced-rovrth�dvc�'{sa �grras�nrir+ticwsjSOUTH ARMOUTH, MA
c. Replace siding with like kind (white cedar shingle)
3. Exterior of house
a. Replace existing bulkhead with a white bulkhead
b. Air condition unit set on side of house by bulkhead
c. Both to be blocked by evergreen trees
d. Add 2 water spigots and backflow preventer
i. 1 spigot rear of the house
ii. 1 spigot and back flow preventer right side of house
e. Remove electrical outlet from front of house to right side of the house
� 9 - A057
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