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21-E023 01,..),___4,..t,� TOWN O F YARMOUTH � � ` ` T- 4 G -I 2 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: Address of proposed work: 400 Center St Map/Lot# Owner(s): Town of Yarmouth Phone#:508-398-2231 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: 1146 Rt. 28 Year built: N/A Email: dcarlson@yarmouth.ma.us Preferred notification method: Phone X Email Agent/Contractor: N/A Phone#: 508-295-5931(Dave) Mailing Address: Same as above Email: Same Preferred notification method: El Phone 111 Email Description of Proposed Work(Additional pages may be attached if necessary): RECEIVED Temporary structure (guard shack) Memorial Day to Labor Day, plus or minus a week APR - 6 2021 APPROVED APR 0 6 2021 OLD KING'S HIGHWAY a YAF MOUTh YARMOUTH I OLD KING'S HIGHWAY i , � Signed(Owner or agent): / ,-c r1 ,,,1 Date: 4/6/21 > Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) ➢ This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date:Lipipta1 /Approved Approved with changes Denied / Amount Reason for denial: i /,/,/!, ,. _ / , I , , d�_,. iii . . 1 �t Cash/CK#: �I��L'vf,G`1 - 1 J f Rcvd by: Date Signed: Signed: APPLICATION#: 117023 V5.2017 �°1Y 0 TOWN OF YARMOUTH F 1-1 1146 ROUTE 28,SOUTH YARMOUTH,MASSACHUSETTS 02664-4451 c� Telephone(508)398-2231 Ext. 1292 Fax(508)398-0836 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE WAIVER OF 45-DAY DETERMINATION The applicant/applicant's agent understands and agrees that due to the current declared National and State public health emergencies the determination of our Application for a Certificate of Appropriateness/Demolition/Exemption may not be made within 45 days of the filing of such application. The applicant agrees to extend the time frame within which a determination is to be made as required by the Old King's Highway Regional Historic District Act. SECTION 9-Meetings,Hearings, Time for Making Determinations "As soon as convenient after such public hearing; but in any event within forty-five (45) days after the filing of application, or within such further time as the applicant shall allow in writing, the Committee shall make a determination on the application. " Applicant understands that the review of this application will be scheduled as soon as the situation allows. Applicant/Agent Name (ple int): Dave Cariso Applicant/Agent signature: ', ,t..4 Q Date:4/6/2 1 Application#: 3/2020 Page 1 of 1 Google Maps Go gi . Maps wkw i Q Ib t tg is o e fig,�, ..•?".a -4 _. .....„. .. 'r1 y , , __,.. 4 ,;„,,...,.....,-,#.16k, vs),1t.,,,.•..4„...4.41 :.. _...!„, may* s, .'''.:74.' • A - * ,Slir.•.,....-•,... T ";ii -,J {' :_,"•<„`Y ti., ".t �°": 02,..-.0‘,.-- t y'4044't4r '� � � k� i� . t l Google ' • " .<. ,, v X . 9 , " stat Imagery©2021 MassGIS,Commonwealth of Massachusetts EOEA,Maxar Technologies,Map data©2021 50 ft eAv ,, I-- '''''- r-''''- ' 0\ _, .7i., , \ / i / J f //JO • ---/j JO0, /\\,.03 *.. fj # , ,,.$ , I Orir# Ji 1 ( A R ., , , c,P� 4 F r ,,,,:ii : -•_,71- \ ® \ . �\ \w _ ~ ° / .. , \ \ 1 .~ . a w: ? . : ? \� 2 :- %� ,m « �, .2 ! < 2. �� y� ..�. . : # « \ < , > i | T,„ „„,,„,_ , nil ' t T . m » e •f e F , . ir , ,. } Alb : } ^ . . ! I • I ) | \ d« . . . . . . . . ,y - 2. . » . . . . . . :.. . . . » _ : , . 1( . \! yr ^ 2 © © a } y \: ' .. } ! � \ � / . . . . , .z : . . . � ` / . .411011-•''' �\,, | « < t \ _\ \ \ ...,..N.,.... N., illiall—",--""f: R -•64..i - _ ''' ,, ..,..-74' ' ,, , BMW d It* ramowalliiiiiiir. i a in , ii., 1 ... _ • alma iiiiihrawo0 . . ....IIIIhe,gmf7m...uimi,h.emuiai...s.4ir.mij.ai„ 4 - lipli: -11........, - .. ,,.. -**'-' -' . ' ' to .,.. ..'-,_,. .., ' . ... -_:-., - ,',.-.,...' :.'.:.,'...-.„'' ':., , , - , ,.,,opoNop7._,,- ''',: ' i .. a tl 6 R 1 4 iv , i .., r PT .YRR ;Office Use Only IPermit# dI r� C5 'Amount 'ta.....1.."'P:rd Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ZIa 0 C /✓1•<— s'T ASSESSOR'S INFORMATION: Map: Parcel: OWNER: A1 d " y jQ.CLwei u )l 4r4' /lr 2-F. NAME PRESENT ADDRESS TEL. # CONTRACTOR: "s/A_ NAME MAILING ADDRESS TEL.# L ❑Residential VeGommercial Est.Cost of Construction$ J ` ` 'T/ • Home Improvement Contractor Lic.# fq/6 Construction Supervisor Lic.# N1A- Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 14 have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED ��'Alpo t -ar 7 57;2-✓LJ X" 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: I gt#4o a 7/"4 rizi.34 S ✓2 52 2 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. ..1t—.�.evocation of m lice and osec n under M.G.L.Ch.268,Section 1. Applicant's Signature: �F • ,/ Date: L. / l Owners Signature(or attachment) Date: Approved By: Date: 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 X Yes ❑ No i� The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 I' Boston, MA 02114-2017 5�•`' _ www.mass.g j� ov/dia orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly - Name (Business/Organization/Individual): '14Address: I ( y (a P-i f, S -L ou, City/State/Zip: 5 . 1 i / /1-641. Phone #: SDI- Z 7/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2.0 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 all work myself. t 9. ❑ Demolition ❑ y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition 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. li.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.t TM c,� y 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other / i,G��" 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ) Date: 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#: 6'NIN Rogers, Grayce From: 'Richard Gegenwarth' <r.gegenwarth@comcast.net> Sent: Tuesday, April 6, 2021 4:30 PM To: Rogers, Grayce Subject: Re: Certificate of Exemption - 400 Center Street Attention! This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email Appropriate design; I approve. Richard On 04/06/2021 12:37 PM Rogers, Grayce <grogers@yarmouth.ma.us> wrote: Hello Richard, I have attached the Certificate of Exemption for 400 Center Street. Thank you, Grayce Rogers Office Administrator Old King's Highway Committee/ Historical Commission 508-398-2231 Ext. 1292 1