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HomeMy WebLinkAboutBld-20-003766 ,—YA w Lance use Only • '.1 Amount MATT M CS -`°""a"' crd 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: Sc 7 3 LiGk S1 d ed (,J. 'farmoulk. 01 13I 0 Z6 73 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: /Ca„f+-. off` / -in'v NAMES PRESENT ADDRESS TEL. # CONTRACTOR: 6 /L..1 -. /200 6eont silyrl It 13Cs/t.,, 146,OZI Zk /-6l7- 567-(octj NAME MAILING ADDRESS TEL.# ❑Residential ,Commercial Est.Cost of Construction$ /© C. Home Improvement Contractor Lic.# Construction Supervisor Lic.# CS - III 2 Y3 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor X I have Worker's Compensation Insurance Insurance Company Name: 4(ra} f2U/v41 .4cLt. CL Cytitt7gd y. Worker's Comp.Policy# --} 'f4"" /9ZN4 WORK TO BE PERFORMED - Tent Duration e'Sc y S (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:_ Sa„N jt,d'k Tit.rts ct„r & ,,4 a4 ¶00✓►1l4- 130 C.SAvtllwtft 1 �4, a2 53/ 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 revocc iioo of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sigrature: !�"' Date: / 7 OW Owners Signature r atta ment) J Date: +r/ 1I Approved By: Date: ` ," -U 2 6) Building Official e EMAIL ADDRESS: • Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 0 No C et w i The Commonwealth of Massachusetts � / Department of Industrial Accidents =el= 1 Congress Street, Suite 100 o Boston, MA 02114-2017 www.mass aov/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): 6-V (A) 'T,- Address: /2 U() e nrmi# S' t . l36,j/z),-N i UZ(Z F City/State/Zip: f i3cu/1 i'M, OD 7C- Phone #: /- 6/7- c6 7 - 6 and Are you an employer?Check the appropriate box: Type of project(required): 1.®I am a employer with 7.5 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. 9. e Demolition ❑ y [No workers'comp. insurance required.]' 10 ❑ Building addition 4.0 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 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.i 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E.]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: ,raj / <,,,&,,re tavari y Policy#or Self-ins.Lic. #: 7 4- /JZr-//A Expiration Date: //// ZO LI Job Site Address: ,SD 7 .6ve lc. iS bt e d X cI City/State/Zip: it). CtirnpP9 /yj/Q-,O r.6 73 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: 4/1:i n� Date: /- 7 26ZeD Phone: /-'/O - 747 - (p y t 7 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#: (triwkay e TOWN OF YARMOUTH r ' BUILDING DEPARTMENT 3 • 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 261 - BUILDING DEPARTMENT TOTAL DEMOLITION SIGN-OFF FORM State Building Code (780 CMR) Chapter 33, Section 3303.6-Service Connections "Before a building or structure is demolished or removed, the owner or agent shall notify all utilities having service connections within the structure, such as water, electric, gas sewer and other connections. A permit to demolish or remove a building or structure shall not be issued until a release is obtained from the utilities, stating that their respective service connections and appurtenant equipment, such as meter and regulators, have been removed or sealed and plugged in a safe manner." "All debris shall be disposed of in accordance with 780CMR 111.5." Building or Structure Location: 34..t-1,ad ed Map: Lot: Owner's Name: - ,,,v, yt. Address: Phone: Contractor's Name: Address: /2096c.un14 4,,,s - Phone: >> 6)7- 5:7- hour, Eversource: Date: E 3aslon r11k�6411 Si By: L, .^� Gi' " '� c t Title: National Grid: Date: ?p,( By: C c mc.(Cc 431. Title: Water Dept.: Date: P- By: PrA, Title: s„, Board of Health: Date: '2-— L t_ .1° 4-U By: Title: 2 Condition: (fit v"-14"- -ryPt r c 7 , Fire Dept.: Date: z -1 l -2-0 By: KE✓,..a ►lu(-- Title: CAPTA ► ►.t 6(0 __ `Date: By: Title: Conservation: Date: 2 //- 2v '1 v By: . Date: 3/15 EVERS=U RCE One NSTAR Way Westwood,MA 02090 ENERGY Feb 11, 2020 Town of Yarmouth 1146Rt28 Yarmouth,MA 02664 RE: WO# 2383447 Disconnect electric service at:74 Town Brook Rd Garage, Yarmouth, Ma Dear Laura, Your request to have the electric service disconnected at 74 Town Brook Rd. Garage,Yarmouth,MA-has been completed as of 2/11/20. Please call me if you have any questions at 508-790-9021. Sincerely, dy WU, Eversource