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Home My WebLink Aboutbld-20-003769 .yq„ '/unice use '�/unly / 44— tO O " ''y . H Amount �, 6�R`""""`°"E�� • Permit 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�-7 Ext. 1261 CONSTRUCTION ADDRESS: Sc? l>VG4 S16Ad �,O?f 73 ASSESSOR'S INFORMATION: E�ju'9me,r S h ec - JU Uf• (' y Map: Parcel: OWNER: -rasp\ r MovN^ NAME PRESENT ADDRESS TEL. # CONTRACTOR: 6 -j-^C. 1/ACC ..Q.. C. 130510 , P14,OZl Zt I-6I7-567-bete, NAME MAILING ADDRESS TEL.# ❑Residential XCommercial Est.Cost of Construction$ .33S MX?,O ) 449k S/< Home Improvement Contractor Lic.# Construction Supervisor Lic.# CS - 2 P3 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: 4r-a,j Mav4 L rittCL Cirvi a, y. Worker's Comp.Policy# /9Z'-/4 WORK TO BE PERFORMED Tent Duration lrQdy 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: Save) :C,et. )It,.gs Ct,r 4s o ¶ 'O,414- 13 D C.Seital mftty/� 41/1, 62 S3 7 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 Signature: !,v "'1 Date: / 7 OLI2 Owners Signature(o attach ent) //_ /ordo� Date: 7 1-4Approved By: �i� Date: ' 7• 211 Building Off-,:;—or.-.i e) EMAIL ADDRESS: • Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 .Imps www.mass.gov/dia Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): (j V L,) Address: /70) e�r7,�,I la , S'I /3dJ Itan 01)4( U2 i1 City/State/Zip: f &c/ i ''M, 07/7 F Phone #: /- 6/ 7- S6 7 - 6 OOL) Are you an employer?Check the appropriate box: Type of project(required): I.®I am a employer with 75 employees(full and/or part-time).* 7. New construction 2.11]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. �� Demolition ❑ y [No workers'comp. insurance required.]t — 4.1: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.E Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.7 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.❑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: k/c.v ✓7 X,4/ 4,/4,<P 4,7,441)4,4/ Policy#or Self-ins. Lic. #: /247 r1 /9ZNA1 Expiration Date: //// ZO Z./ Job Site Address: S 7 8vG lc. ers /eewd Xol City/State/Zip: 10. (i i,uv�(,� AVM.,O 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: Date: / 7 22)z Phone#: /-4/0 - 7c/7 - 0 y I 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 m: o .YgR TOWN OF YARMOUTH $ BUILDING DEPARTMENT 0 . -H: MATTACM 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 accord nce with 780CMR 111.5." Building or Structure Location: Wz3,e4...rs444 itc Map: Lot: Owner's Name: TU.N.off • Address: Phone: Contractor's Name: wW Address: /7,a, ",, 31. Phone: /-6 a 1- 567- 6 coo 41 Eversource: Date: C'46 f°" A.ozitY By: Title: National Grid: Date: By: Title: Water Dept.: Date: By: Title: '�n rrn. C Board of Health: Date: By: Title: Condition: / /\_, Fire Dept.: Date: By: Title: J Historic Commission: Date: By: Title: Conservation: Date: By: Comcast: Date: 3/15