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HomeMy WebLinkAboutBld-20-003767 O7Y` 44 • ice use��jjonl_y, °37 • t y` '7 Amount 1 • MATT- e+ is � 4""*'u`o°erd Pennit expires 180 days from 1 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: 507 3 UG4 6i4A if„,^ckAk. ()� Q Z.6 73 ASSESSOR'S INFORMATION: Palace (1ce~`kc.vQK.(x- 6 — 6/UC4. Map: Parcel: OWNER: 'rasp, of` 75r Mlv NAME PRESENT PRESENT ADDRESS TEL. # CONTRACTOR: 61/t.) +( . /200 13ennr SI-, C 13o r, 414-,OZI Zt l- I7-5t;7-beet) NAME MAILINO ADDRESS TEL.# ❑Residential Commercial Est.Cost of Construction$ 3 S-tvo Oc? /v 1< Home Improvement Contractor Lic.# Construction Supervisor Lic.# CS - III 2 P3 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor X I have Worker's Compensation Insurance Insurance Company Name: A/ra.,I M1/v4I leViirwiCL £ i #i y. Worker's Comp.Policy# /9Zyi4 WORK TO BE PERFORMED 4 • Tent Duration ‘0S4 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: S„�CL; k f,ems cL,r S ,.k c rt - 13© C.SAi1{I,,,Art o14, 052531 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 revoc io of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: r p Date: /' 7I OZt7 Owners Signature(o attachmept) /� Date: iI 7 1-0 Approved By: 4 v Date: ' 7 ZQ Zc.) Building Official(or desig EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No . The Commonwealth of Massachusetts ' W--, IDepartment of Industrial Accidents �- 1 Congress Street, Suite 100 �_ 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): 6'V IA) T,' C , Address: I7O) geOr MI1 A' S1 t . 13ds AN I- v2 iz City/State/Zip: f t u/,-t iM, 071 7 k Phone #: /- 6/7- SG 7 - 6 and Are you an employer?Check the appropriate box: Type of project(required): I.gi 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 all work myself. 9. ��� Demolition ❑ doing y [No workers'comp. insurance required.] 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 i i.❑ 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.; 6.0 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#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: dram) 41ellti4/ <,,,, ,re /rip etw y p,4. Policy#or Self-ins.Lic. #: /%twig Expiration Date: /1l/ Zv Z Job Site Address: ,SO 7 & I.. .S 14wi Xd City/State/Zip: 4). (4tmajiti MIA-,Or.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 unde the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: / 7 Zr)Zv Phone#: /-6/O - 7f7 - OW 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#: :o YAR TOWN OF YARMOUTH c. BUILDING DEPARTMENT n„C„ ES 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 261 -- BUILDING DEPARTMENT E .: 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: 507 &A-134•J eel Map: Lot: Owner's Name: Address: Phone: Contractor's Name: G vw ?mac. Address: ZvopeAo° b,s/- Phone: i-617-56'7-6Ov0 e:0as 0t1t Eversource: Date: �► , By: „��. ,,.,,r K P1 c Title: National Grid: Date: `` {41\ By: ��z� /vl,t,�, ` bf s�-ti �- Title: Water Dept.: Date: /'Z `2- By: Alt. Title: „�lx�t�•v� Board of Health: Date: -�� 1-c By: pl../.-"A's Title: -poet • Condition: _ ft c e"`d -�C Fire Dept.: Date: .47- ° By: )/ v Title: t-A PTA 7 H 0 C-i Historic Commission: Date: By: Title: Conservation: Date: 2-'7/"2 e'ZO By: . Comcast: Date: 3/15 EVE RS=URCE one NSTAR Way Westwood,MA 02090 ENERGY Feb 11, 2020 Town of Yarmouth 1146Rt28 Yarmouth, MA 02664 RE: WO# 2383449 Disconnect electric service at:74 Town Brook Rd,Yarmouth, Ma Dear Laura, Your request to have the electric service disconnected at 74 Town Brook Rd. Yarmouth, MA-has been completed as of 2/11/20. Please call me if you have any questions at 508-790-9021. Sincerely, Eversource nationa{grid January 30, 2020 GVW Inc 1200 Bennington St E Boston, MA 02128 To Whom It May Concern RE: 74 Town Brook Rd,W Yarmouth(Bldg&Gar) This letter is to confirm that National Grid has cut and capped the natural gas services at the property above. I can be reached directly at 508-760-7484 should there be any further questions. Path eldon nationalgrid Senior Acct Mgr,Customer Connections 127 White's Path S.Yarmouth,MA. 02664 508-760-7484 desk 508-400-5051 —cell 508-394-1109 -fax patricia.weldon@nationalgrid.com 02/07/2020 09:05 (Town of Yarmouth - Live IP 1 mcfranklin SUB Service order lutworkor Date Entered: 01/21/2020 District: 03 Account Type:MU Entered By: jjohnston Reference: 82024 Account #: 03003193 TOWN OF YARMOUTH CID: 78639 Default route:43 99 BUCK ISLAND RD Read Seq: 1560 W. YARMOUTH, MA 02673 Parcel : 045.91 Location: 74 A TOWN BROOK RD Desc: Subdiv: Lot: Service : 100 -001 WATER CONSUMPTI Meter Info. Manuf/Serial Manuf/Serial Read Meter IP 78536249 Other Meter Installed Date 05/17/2016 # of Dials: 4 Size: .625 Remote ID • Read Info. Service Comment: AMR L/SIDE Year/Mo R Reading Billed Usage Year/Mo R Reading Billed Usage 2014/ 9 A 53 1 2008/ 9 A 38 3 2013/ 9 A 52 2 2007/ 9 A 35 3 2012/10 A 50 2 2006/10 A 32 3 2011/10 A 48 4 2005/ 9 A 29 4 2010/ 9 A 44 3 2004/10 A 25 4 2009/ 9 A 41 3 2004/ 6 21 Reason Code: OTH OTHER MISC Sery Order Type: MISC MISCELLANEOUS SERVICE Assigned To: WETH PAUL WETHERBEE Date Scheduled: 01/23/2020 Time Scheduled: Addl Services: Manuf/Serial Reading Comments: CUT AND CAP, 74 & 74A MARK 781-583-8208 DS20200101609 In o: C/C 2 SERVICES AT TOWNBROOK - BILLED GVW $1210.00 FOR C/C INSTALLED ME TER PIT - TOWN WILL NOT CHARGE FOR WATER PER CONTRACT hC k Co : BT Date Completed: 01 Comp - •eason: