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Home My WebLink AboutBld-20-004395 4Y4`9R ,vmce use vnty • C ,x . H 'Amount ` ATTAcn CSE,� '�`°"°'"°"°rp I Permit expires 180 days from issue date t C�E I V E EXPRESS BUILDING PERMIT APPLICA , TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 /,It�l � 6cF'ARTM � South Yarmouth, MA 02664 g�BE. _' (508) 398-2231 Ext. 1261 �/ CONSTRUCTION ADDRESS: —7 ". 3 "/ v ' /� /444,4,4,c, ASSESSOR'S INFORMATION: Map: Parcel: OWNER: s 7 .6y/t„ % eA,•- 5 7 ?.SeCgiCn NAME //�� ! PRESENT ADDRESS TEL. # CONTRACTOR: �"L—(//G 5'. Pe y�.�4/ 26 C1.44 N jt(7' C-,PO- `J ag NAME J MAILING ADDRESS Cj/; TEL.# ❑Residential €ommercial Est. Cost of Construction$ .6?,� '4?'"'C -7 Home Improvement Contractor Lic.# /5 3 ' �3 Construction Supervisor Lic.# / .* 6 / O -" Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor E: I have Worker's Compensation Insurance Insurance Company Name: / 1- ��.._I' Worker's Comp.Policy# - iwe'c >22c.4 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /6 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: 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) ® 1/ Date: Approved By: Date: N. )0 s� 6 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes E No Flood Plain Zone: Ei Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No D Yes No The Commonwealth of Massachusetts f _� �� 1, Department of Industrial Accidents 1 Congress Street, Suite 100 =R- Boston, MA 02114-2017 ..5• 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): C Address: C7 , City/State/Zip: __ Phone : Sad �-3 7 Are you an employer?Check the appropriate box: Type of project (required): I g 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.] — 9. Li_ Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t - 10 Building addition 4.I1 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. 13.El 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.El 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. :Contactors 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. rr: l,'.C. 5 j /8 S9 a9cg e Expiration Date: 4/1/3a4c,2 0 Job Site Address: S .( 5Lp r a- City/State/Zip: GL�. .� Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ains and penalties of perjury that the information provided/6. bove is true and correct. Signature: Date: 2 / C Phone#: 5�r% '-3"?. OrS f �? Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone m: F2 E AL TY 299 Main Street, West Yarmouth, MA 02673 508-775-6880 Fax: 508-775-6939 E-Mail: horansh@comcast.net February 4, 2020 To: Town of Yarmouth Building Dept From: Shawn Horan • Re: Foxwood Condominiums Building G To Whom it may concern, Please note that CF Remodeling Inc has been retained to install siding to building G at Foxwood Condominiums, 248 Camp St, West Yarmouth MA.. Sincerely yours, Shawn Horan Cape Realty Inc SALES RENTALS REAL ESTATE MANGEMENT BUYER AGENCY www.caperealtycapecod.com Commonwealth of Massachusetts / 1"4-1Division of Professional Licensure JJ Board of Building Regulations and Standards Const\ru>rt$/f%bpe,rvisor C$ 1. g4107 > b 4,1 Spires:08/25/2021 4. CARLOS H FJGUEt • r f, t- 20 CAPTAIN NOYES 4°9 v «i•: ,44. SOUTH YAR? UTH •64 '6" Commissioner (..u �