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Home My WebLink AboutBld-20-003617 O l.1uicc vac only 7V Amount Permit expires 180 days from i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH • Yarmouth Building Department 1146 Route 28 #/�y South Yarmouth, MA 02664 45-7}4e' l (508) 8-2231 E 1261 4; CONSTRUCTION ADDRESS: 1Adi/ J� _. y a i/ /tf Z'-/-* ASSESSOR'S INFORMATION: &k: ,4q`f/( , Wigeaj/ Map: Parcel: `66,, OWNERUV%! $J) Loth,' / Wfj i(��NAMEPRESENT AD TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ U V v 740 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) A.I am the homeowner 0 I am the sole proprietor 0 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 ""? *The debris will be disposed of at: % �/ G,,��.u1f 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 denial or rev . of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:c--- '—' Date: /06/9" Owners Signature( attachment) Date: Approved By: _/...L::.." Date: ) —17 //5 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes No Flood Plain Zone: 0 Yes 01 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts 1 L Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 °1�„O r•'� 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/Individ al): l(t12 0 6L_s1d Address: N W/i 1.1-e 0 , City/State/Zip �,,/7L (�o�l� jphone 4: ()g - �!��- cj -57f Are you an employe ck the appropriate box: Type of project(required) 1.❑ 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.] 3.E I am a homeowner doing all work myself [No workers'comp. insurance required.]I' 9. ❑ Demolition 10 E Building addition 4.EI 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.Q Plumbing repairs or additions b.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. j; ❑Roof re airs These sub-contractors have employees and have workers'comp. insurance. • 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Othe // /f/2,1 152,§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-contactors 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 c u der the pains a penalties of perjury that the information provided above is true and correct. Siena e: Date: /Z 7//9 Pho ;,-: 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#: • °74 TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 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: / / / �j�a Address of prod work: l ,S7 L' ,/,/ /•f f' ,e� rt G�L • Map/Lot# Owner(s)00cia-r lm/7 Cr%d•&.�Q- C / / Phone#:t� 277` J All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: Year built: Email:SMa-0-'712 9 ! e L J/22//. ('�I Preferred notification method: Phone Email -- Agent/Contractor: Phone#: Mailing Address: Email: Preferred notification method: Phone Email Description of Proposed Work(Additional pages may be attached if necessary): / �f UC M/ Gf'"- Lt//YJ tr4m/>2 /6,0,7 re6h/q/c c7(4k .:, (//. a///,,/, tv /e,-, /(ido4/-/-%,..- 4//-jr-i ._._..‹. Signed(Owner or agent '- ` If _ IgiAPPROVE > Owner/contractor/agent is aware that a permit may be required from the Buil > This certificate is good for one year from approval date or upon date of expir APR 2 fl 201 For Committee use only: Date: Y- t9-t 8' •.,Appd---__. _. -.— Amount 020 Reason fo`tA 0 Cash/CK#: G�� csH APR a zat Rcvd by: 6'Y 01101fIlSi.GS HIGHWAY t Date Signed: Zofzoi, Signed: , •,Z. ', iL L� a APPLICATION#: )� V52017