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EXPRESS BUILDING PERMIT APPLICA .4 - --
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TOWN OF YARMOUTH
Yarmouth Building Department • {
1146 Route 28 1 ' FEB '3/ ZIPJ 1
South Yarmouth, MA 02664 L-- -., .._ . ..�
BUILDING DEPARTMENT
(508) 398-2231 Ext. 1261 By
CONSTRUCTION ADDRESS: _yr., 14:: -' �� ,� t /'v- J 'Y . ec.-4 _ L
ASSESSOR'S INFORMATION:
/ Map: Parcel:
f
OWNER: . i f y;a W/✓ H'[) ea %✓ �& 7 7.5 C 8 O
NAME / PRESENT ADDRESSn �� TEL. #
CONTRACTOR: ( lC S �!Cl -1'l�'1•00 00 6t- 1/4r/na*`" 6.'�'YF • s C2�'.,237 yS -11
NAME ,../ MAILING ADDRESS s ,✓ a gTEL.#
0 Residential „KCommercial Est. Cost of Construction$ 8 C' CC C�
Home Improvement Contractor Lic.# /5 0 q 3 Construction Supervisor Lic.# / G V / 0 7
Workman's Compensation Insurance: (check one)
Esi I am the homeowner I am the sole proprietor �I have Worker's Compensation Insurance Insurance Company Name: t� co"vi Worker's Comp.Policy# IA'ic 500 / (eS'?Zc%)O 4-
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares IC/ 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: l.,4A/1",%4L.C.4...;&91 .
Location of Facility
I declare under penalties of perjury that the state ents 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 'cense and for prosecut' „Cr L Ch.268,Section 1.
Applicant's Signature: -qS Date:
Owners Signature(or attachment) �6 d Y,y/- Date:
..._..--.
Approved By: (--""--(y Date: a`" )0 " (),U
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes n No
Water Resource Protection District: Within 100 ft.of Wetlands: J
❑ Yes 0 No E Yes = No
.' \ The Commonwealth of Massachusetts
Department oflndustrialAccidents
_ _r 1 Congress Street, Suite 100
�• __I Boston, MA 02114-2017
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): t y S 4% c%c
Address: 20 yt4 c7/
City/State/Zip: ,S 4 Phone #: sae 2 37 7S '
Are you an employer?Check the a ropriate box: Type of project (required):
l. �.: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. [[J Remodeling
any capacity. [No workers'comp. insurance required.]
9. ❑ Demolition
3.E I am a homeowner doing all work myself [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.❑ 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.Ei Roof repairs
These sub-contractors have employees and have workers'comp. insurance.
6.E We are a corporation and its officers have exercised their right of exemption per MGL c.
14.n 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: 6G
Policy 4 or Self-ins. Lic. P✓CC 6"Cr) 30 / t 05Y 2.(26,4 Expiration Date: 3 �/ / )-CJ
Job Site Address: Y Cs�-.�- %S 7 . /L() L- City/State/Zip: , y44
Attach a copy of the workers' compen tion 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 correct.
Signature: Y ""e16'...... .... . .. ... �..... Date: .illPhone#: yo 9 ' 15 9 2
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 4:
1
I NJ
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 II Condominiums Building L
To Whom it may concern,
Please note that CF Remodeling Inc has been retained to install siding to building L at
Foxwood II Condominiums, 248 Camp St, West Yarmouth MA.
Sincerely yours,
Shawn Horan
Cape Realty Inc
SALES RENTALS REAL ESTATE MANGEMENT BUYER AGENCY
www.caperealtvcapecod.com
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Commonwealth of Massachusetts
Division mProfessional uconsu,o `] '
Board of Building Regulations and smnuums
Con 6 isor
� res:O8/25/2021
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