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Home My WebLink About21-E023 400 Center StI TOWN OF YARMOUTH ;{TI -0 r, 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 Telephone (508) 398-2231 Ext. 1292 -Fax (548) 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 # owners): 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: NIA Email: dcarlson@yarmouth.ma,us Preferred notification method: Phone X Email Agent/Contractor: NIA Phone #: 508-295-5931(Dave) Mailing Address: Same as above Email: Same Preferred notification method: R1 Phone R1 Email Description of Proposed Work (Additional pages may be attached if necessary): Temporary structure (guard shack) Me MUFlai uay I:O t-aovr i APPROVE APR 0 6 2021 lay, plus or minus a week RECEIVED YARMOUTH OLD KING'S H111 'WAY Signed (Owner or agent): 0�Date: APR - 6 2021 YARMOUI"r, > 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: L Amount Cash/CK #: Rcvd by: Date Signed: V5.2017 ZApproved Reason for denial: Signed: Approved with changes Denied APPLICATION #: f °F 0 TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-4451 416WJ 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 nt}: Dave Carlso r V Applicant/Agent signature: 71 Application #: 312020 0 Il ®❑ m I ?,OW r I i �Il��ia 1 ; � } Q l Umce use Only 0 Permit#, O c6 c Ll 5 Gi 3 Amount s S •z�9 E 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: I-Ja 0 C e,4/ 71 Ir— ASSESSOR'S r-ASSESSOR'S INFORMATION: Map: Parcel: OWNER: fic�V-O^J p 12-T 2 F NAMEJJJ ld� PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL. # / - ` ❑ Residential 4omj mercial ._ I Est. Cost of Construction S 5 i <j 'T Home Improvement Contractor Lic, # P Construction Supervisor Lic. #. tj/ A oF Workman's Compensation Insurance: (check one) J G I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# WORK TO BE PERFORMED T�cw►,ov r— f y e 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: d l� r9ol" E /_1 `� 52> /r%� 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 evocation of m lice andosec n under M.G.L. Ch, 268, Section 1. XApplicant's Signature: Date: vz� L Owners Signature (or attachment) Date: Approved By:Date: Building Official (or designee) EMAiL ADDRESS: Zoning District: Historical District: A Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 1 0 ft. of Wetlands: Cl Yes 0 No Yes CJ No The Commonwealth of Massachusetts y Department of.IndustrialAccidents I Congress Street, Suite .100 Boston, MA 02114-2017 �•` _ www. mass.gov/dia 1 orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Al2plicant Information PIease Print Le4ib1 Name (Business/Organization/Individual): T� bLA-`0'/4 dyl—I ty nxz W - n 1. T* Address: I i 9 (o P__f_ 1?— f S' , ' City/State/Zip: 5 . rKo-wcr,,-/ 1W- Phone #: Sd f - 97,F Are you an employer? Check the appropriate box: l .❑ I am a employer with employees (full and/or part-time).* 3.r� I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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 proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp, insurance.t 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction S. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. Roof repairs 14. FA � Other Fn e rz$Z2 �` T ,y a�,N„U4„L wat ciiac�s oox 7F L must also nu 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, tContractors 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 andpenalties ofperjury that the information provided above is true and correct. 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 ?. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6, Other Contact Person: Phone #: Rogers, Grayce From: 'Richard Gegenwarth' <r.gegenwarth@comcast.net> Sent: Tuesday, April 6,20214:30 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