HomeMy WebLinkAbout22-EB016 149 White Rock Road ApprovedSherman, Lisa
From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net>
Sent: Tuesday, February 22, 2022 9:26 AM
To: Sherman, Lisa
Subject: Re: 22-EB016 149 White Rock Road
Attention!: This email originates outside of the organization. Do not open attachments or click links unless
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Good. like for like. I approve.
Richard
On 02/22/2022 9:10 AM Sherman, Lisa <lsherman@yarmouth.ma.us> wrote:
Hi Richard,
APPROVED
FEB 2. 1 2022
YARM(DU T H
Like for like, replacing the picture window with Anderson bay window.
Please let me know if you need any additional information.
Thanks Richard,
Lisa
Lisa Sherman
Office Administrator
Old Kings Highway Committee/Yarmouth Historical Commission
Town of Yarmouth
508-398-2231, ext. 1292
lsherman @ yarmouth.ma. us
1
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RESS BUILDING PERMIT APPLICA
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 4� rll J-
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ASSESSOR'S [NI=ORN4ATION:
Office Use Only
Pcrmitf
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Permit erpires ISO days froin
issue date
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KING'S H!GNV 411
Map: Parcel:
OWNER: H9 W — 3 7— q -7.)3
NAME PRESENT ADDRESS TEL. i
CONTRACTOR: �a r P-0. 90 y 2 -2 q - 3 S3 - i� 8 S -Q -
NAME MAILING ADDRESS TEL. #
Residential ❑Commercial Est. Cost of Construction $ VIP
3 SDD
Home Improvement Contractor Lic. # 1 (o 5-8 �[J - Construction Supervisor Lic. # G5— 06 1 0li c
Workman's Compensation InsuranXl'wn
heck one)
0 I am the homeowner the sole proprietor
Insurance Company Name:
0 1 have Worker's Compensation Insurance
Worker's Comp. Policy#
WORK TO BE PERFORMED
Tent D Duration (Fire Retardant Certificate attached?)
Siding: # of Squares Replacement windows: #
Roofing: # of Squares (❑) Remove existing* (max. 2 layers)
Old Kings Highway/Historic Dist. O'Replacing lilce for Eike
*The debris will be disposed of at:
Location of Facilih-
Wood Stove-0—
Replacement
tove__
Replacement doors: #
Pool fencing
Jnsulation[—�
I declare under penalties of perjui that to st mems hercin contained are true and correct to the best of my latowledge and belief. I understand that any false �•uiswer(s)
will be just cause for denial or r ti n a y license and for prosecution under M.G.L. Ch. 268, Section 1,
Applicant's Signature. Date:
a�
Owners Signature (or attachmei3t} Date:
Approved By: Date
Building Official (or designee) E-MAIL ADDRESS
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes . No
Water Resource Protection District: Within 100 ft. of Wetlands:
Yes No Yes No
The Commonwealth of Massachusetts
NVEDDepartment oflndustrial'Accidents : ° PROV 9 f
j I Congress Street, Suite 100
FEB 2 2 2022 Boston, MA 02114-2017 FEB 2 2 2022
iV�y'y www.mass.gov/dia ; ARMOUT ,,- '
l orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluni 'S Hl
TO BE PILED WITH THE PERMITTING AUTHORITY.
Name (Business/OrganizationlIndividual):
Address: . 60X .7qq
City/State/Zip: 7 -
A ad-�7
Are you an employer? Check the appropriate box:
Phone #:
I.❑I am a employer with employees (full and/or part-time).*
0 1 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. 1 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.:
h.❑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. E] New construction
S remodeling
9. ❑ Demolition
10E] Building addition
I I.E]Electrical repairs or additions
12. Q Plumbing repairs or additions
13. []Roof repairs
14. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
r 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
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 certi; f uKdVr t ypair�r 7d penalties ofperjury that the information provided above is true and correct.
- Date: r�/1>0
-?,V- 3
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 #: ;D_e66J L
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Commonwealth of Massachusetts .
Division of Professional Licensure
Board of Building Regulations and Standards
Const recti ori "§tipery i s or
CS -081040 EXpires: 04/0412022
PATRICK H JACOBS
28 WHITTIER DRIVE
DENNIS MA 02538
c.
Commissioner
Office at Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE: Individual
Registration Expiratior,
155888 05114/2022
PATRICK JACOBS
D/B/A P. JACOBS CUSTOM CARPENTRY AND
REMODELING
PATRICK JACOBS
28 W HITTER DR.
DENNIS, MA 02638 Undersecretar
VIF
FEB 2 2 2022
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APP D
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Chad & Margaret Benaka
149 White Rock Road
Yarmouth Port, MA o2675
February 19, 2022
Town of Yarmouth
To whom it may concern:
FEB 2 2 2022
Yf;Fii4iUu rr
We allow Pat Jacobs to replace our front bay window and do work at our house
(149 White Rock Rd, Yarmouth Port, MA 02675).
Sincerely,
?7 /7
Chad & Margaret Benaka
508-237-9723
Chadbenaka@gmail.com
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FEB 2 2 2022
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