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i; t I i'AR
EXPRE I`-- t"DTNG PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
t�J (508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 1 b 0 kci j 4 to A 1/ J�) O,V, ) ®a L.-7
ASSESSOR'S INFORMATION:
1
Map: I Z Parcel: LI 1
OWNER: V( 5A � ( K 1-P s.os 6, - t�. 7 7 5
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
❑Residential ❑Commercial Est. Cost of Construction$ 5 +`
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
1 I am the homeowner ❑ I am the sole proprietor I I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED �nc,-L S
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:
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) . Date: 3/l 3 JZ
Approved By: Date: J -/?
Build ff (or esignee) L ADDRESS:
oning District:
Historical District: U# Yes 2 No Flood Plain Zone: Yes 2 No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes ❑ No Yes 2 No
The Commonwealth of Massachusetts
r 1 /. Department of Industrial Accidents
1 Congress Street, Suite 100
.' Boston, MA 02114-2017
'iM IMP 5•''y
www.mass.go v/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):
Address:
City/State/Zip: Phone L:
Are you an employer?Check the appropriate 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. E Remodeling
any capacity. [No workers'comp. insurance required.]
3. I a homeowner doing all work myself. 9. ❑ Demolition
y [No workers'comp. insurance required.]t —
4. am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 _ Building addition
P property.
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
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp. insurance.:
o. 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 41 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-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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 31131-2-
Phone#:
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#:
• Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
•
An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Deparment has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
r Boston, MA 02114-2017
Tel. 4 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax T 617-727-7749
Revised 02-23-15 www.mass.gov/dia
•
Iv;ic,_l At
,l°` "o TOWN OF YARMOUTH
ip 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836
air
� TKING'S HIGHWAY HISTORIC DISTRICT COMMUTER t ' -
APPLICATION FOR _
TOWN v (��.f
CERTIFICATE OF APPROPRIATENESS
J . i�l�
� T _ 'fl 1
Appli ' )i'o i h��r ' d4"fdr• issuance of a Certificate of Appropriateness under Section 6 of Chap r 4�70,�p -���'as .
amended,for proposed work as described below&on plans, drawings, photographs, &other supplement info accompanying t '{e-'_'_
application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S), ELEVATIONS, PHOTOS,&SUPPLEMENTAL INFORMATION.
Check All Cateaories That Apply: Indicate type of Building: Commercial „/Residential
1) Exterior Building Construction: New Building Addition _Alterations Reroof Garage
Shed Solar Panels Other:
2) Exterior Painting: Siding Shutters Doors _Trim Other:
3) Signs/Billboards: New Sign Change to Existing Sign
4) Miscellaneous Structures: Fence Wall Flagpole Pool Other:
Please type or print legibly: ;� I _ I l
Address of proposed work: I D I -- ou Tc (i A \�,(�h?1LA4 ,pol NA Map/Lot# I..)a J y/
1 dL�. -7.,
Owner(s): K/1 511 nA 5 (/f)( l-e Phone#: B OSS- 772,-j 77�J
All applications must be subhiitted by owner or accompanied by letter from owner approving submittal of applicatood
Mailing address: 50'-12. Year built: 060
Email: l2J I3 \cpYi nk i0 /i L. -C i Preferred notification method: ✓ Phone Email
Agent/contractor: Phone#:
Mailing Address:
Email: Preferred notification method: Phone Email
Description of Proposed Work:
-2.1 Pf. z F 1 -reNc E ‘ivoo to . I t�1G 4+6 1 tUl Or( liV I S ca.�+ 4 ->'-I-)t Yr )5 A
C3mY- Lfc )6' ) 14,r -)(/n l )ol )-., I,j l� ( 0)/ ►mili,ll1i W15 Sh)/1) )0NifJ V 1l
I J � � �
Signed(Owner or agent): /� s pj,//r, �( Date: 1 /8)/y
➢ Owner/contractor/agent is aware that 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 subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections.
For Committee use only: __ pproved /Approved with ) Modifications Denied
Rcvd Date: la'88.'1 q1 Reason for Denial:
Amount aJ
Cash/CK#: 3(p CO Signed: C?iliakti i
VRcvd by: ( _ C cam-4
45 Days: 11. ao1. `'1 L ......,
} y.z,-
Date Signed: !/// 2'/2 c'i 7
lag g,i94 Co114- n0ca -ta II.1a. 19 ,oer,d.,� -vSed ,ola..,s .
A.1f11 1"A T1I1A 1 Al.
9 - A 0 8 9
MODIFICATIONS TO
CERTIFICATE OF APPROPRIATENESS
Date: ( t 112-1/2523c9
C/A Number: l Cl-k-Cncla Address: I cU� i(etoSU-r--r".64\-
1. ` ( ( G� -Fc AJ3 t
(----nr--2 l 1c),! C-�-c j (•
2.
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I agree to the above conditio s and cha es to the Certificate of Appropriateness:
Owner/Agent: OKH: ,��_
GENERAL SPECIFICATION SHEET
Project Address:
FOUNDATION: Material_ Exposure (Not to exceed 18'):
CHIMNEY: Material/Color: GUTTERS: Material/Color:
ROOF: Material: Pitch (7/12 min) Height to Ridge Color
SIDING: Material/Style: Front: Sides/Rear: COLOR CHIPS
Color Front: Sides/Rear
TRIM: Ali windows & doors to be trimmed with: 1x 4 1x5 (Circle one.)
Material: Color:
DOORS: Qty: Material. Color:
Style/Size (if not listed/shown on elevations):
STORM DOORS: Qty: Material: Color:
GARAGE DOORS: Qty. Mat'I: Style Color:
WINDOWS: Qtv/side:: Front: Left: Right: Rear. Color: , /
Manufacturer/Series Material:
Grilles (Required): Pattern (6/6, 2/1. etc.) Grille Type. True Divided Lite:
Snap-In: Between Glass. Permanently Applied Exterior Interior
STORM WINDOWS: Qty. Material. Color ,�,` 'e"^;cm
SHUTTERS: Matl- Style Paneled Louvered Color.
SKYLIGHTS: Qty: Fixed Vented Size Color:
DECK: Size. Decking Matt. Color:
Railing Matt Style: Color
WALLS/FENCES* (Max 6'height): Height: Mat'l
Style. Ft Color: t "
(Show running footage& Iodation on plot plan.) *Finished side of fence must face out from fenced in area
UTILITY METERS/HVAC UNITS: Location: Screening:
LIGHTS: Qty: Style: Color
Location(s):
LIGHT POSTS: Qty: Material. Color:
Location(s).
Additional information
2-General
APPLICATION#:
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R EC E[VT-',.. PROPOSED FENCE LOCATION PLAN
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NOV ! 3 2u ? YARMOUTHPORT, MA
TOWN � ( E-i'K
ASSRS. MAP 122, PARCEL 41
SOUTH YARt,;;..i!i-H,
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