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', , -,, --I- , .1 --! , ,_,, _ ,__ , ---,, , , , , , , , . ...„--- ) i —, 1 1 i, id , 1 i , , ,• , : , i, d, , ., ,, ___,, t, _ I:1 , •,, „.....,_, 1 1 ,..._ .i. ,. , : , i . 1 : . , --i, 1 k 1 i 1- I . , I , , , i i , 1 1 , , I. 1 , i i , i s 11 3 : I I'; - \-/- -1 —j. . : 1 I II:, 1..._ I I , , : ,, 1 , , , ' 1 , -,, H -•i- 'I Ill 01•Y<qR Uihce Use Only ,�' 1. ,� :rc _ .. •-..Il ;Amount ve MATTACN ESE J� k`°""`s`��e `r Q D Permit expires 180 days from g f �� c (V ' l 1 l issue date EXPRESS BUILDING PERMIT A PLICAT ON TOWN OF YARMOUTH 4W X'- v Yarmouth Building Department 1146 Route 28 ' South Yarmouth, MA 02664 F � (508) 398-2231 Ext. 1261 ; t , , { i, c Y i CONSTRUCTION ADDRESS: ,_ INANIR�I, 0P�,S: 1.,,N.N °� ASSESSOR'S INFORMATION: Map: ( Parcel: 6 OWNER: C +- J Eci\t g W\1l.-'Cl-. YI-T Z -ZR 014- 0 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# 4© Edential 0 Commercial Est.Cost of Construction$ t_���. Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) N.-Km the homeowner ❑ I am the sole proprietor ❑ 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: ,©3N. C,C\-t c .ts®\S—S-4- Location of Facility I declare under penalties of perjury that th -atements 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 de ial or revocat. of my license and for prosecution under M.G.L.Ch.268,Section 1. '� XAPplicant's Signature: AD--' L, ( Date: f —Z0—k 1 X Owners Signature(or a chment) ) Date: 1‹-- ,C) 1 1 Approved By: Ie........"... Date: CI Building Official(or �• �designee) EMAIL ADDRESS: ��� ���! Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,.5�• www.mass.00v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): G L S -4— —3-ii\t•Nt € CNi-re Address: City/State/Zip: WesryNe, 1-k VA ©),L73Phone #: ~! 14- 2-2g c (o Are you an employer?Check the appropriate box: Type of project(required): 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.] _ 3. I am a homeowner doing ail work myself. [No workers'comp. insurance required.]t 9. _ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYP roPertY• I will I O Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.E 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.t. 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other (1 ikp{NQ 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-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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb certify u Me pains and penalties-of perjury that the information provided above is true and correct. 4,nature:_ O Date: C Z..-2.o -t q Phone#: 1 � Z.a(8 b��b Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: P1.A'wEO ILO 3- '4-c o SY ear ON Alp ,g.p ' 1 l..ST T..AA • J N • rl s tli . / w_ .-E //a.a 0 v • I • % EZ.3sAZ Vol v to • ii,sq op cci: f ; ct NT- ;X$? 1 N 4--28't ' t( �Fi 6c.z3.1 . ait `\1 `� i 1 • \ .r - Ec.z9A w C/G • GO'r/1a 6 . Pu BL/c. - • • , .No7'c-EoV oNs 409s6O env fr/a;MP-S45.4 PSEa GEVEG • • CERTIFIED PLOT PLAN ...... ..._....- EDWARD E. KELLEY oiikAAQUID;. MASS: 02637 ------- - - - ..LOCATION Wt 4 �/.4,¢i;Jo(4TAe.).e47494.47... ;,,, SCALE I ii`301 _ - DATE Ea???7/Afk).--. ... � (``. PLAN REFERENCE .a4/ /G .4or..'�4/ :1 ` .. mown/ voN to Cout¢T: . Ti_. ;:"; 7 plg� , .40 .949..E4414-c .z . ib f� ��``` _ ....`�.. . ei„ •�•c"„`•�' • I CERTIFY THAT THE 4-'x15TiNG F0.4)4L?tiro.>`l.'. • SHOWN ON THIS PLAN IS LOCATED ON THE GROU Lo7' 4- 1/ . • AS SHOWN HEREON AND THAT IT CONFORMS TO TH al SET CK REQUIREMENTS OF THE TOWN OF !! (j • BARAt8oAR D Con✓57,eucT'iow �IRI�aVrN WHEN CONSTR . 76 8AyPo#v7 /RA7r# • DATE Ea.Zi./.4?$0. • PETITIONER: JyA1e NAEGO M�955 • ){J G� sio4 r. S RY REGISTERED LAND SURV OR ;� .-. . .. ....... ..---...._____.---- _____________