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HomeMy WebLinkAbout22-EB068 35 Route 6A ApprovedA RECEIVED N- JUN 0 2 1022 ��rwnu i,d 'AhtMOU i i 3 rli n vu.r..n ............. . EXPRESS BUILDING PERMIT APPLICA TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA.02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: -3-S— K f � 6 A Wfilb U j ASSESSOR'S INFORMATION: Office Use Only Perm0 Amount Permit expires 180 days from issue date TED JUN 0 2 2022 YARMOUTH Map: Parcel: OWNER: & iL CY n NAM�yE, PRESENT ADDRESS TEL q CONTRACTOR: i r `J� n� �_c_ Co- }1- NAME MAILING ADD ESS TEL. 4 $Residential ©Commercial Est. Cost of Construction $ Home Improvement Contractor Lie. N /� %-,2yl Construction Supervisor Lie. # 1696-> & Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ave Worker's Compensation Insurance Insurance Company Name: —2— is' < Worker's Comp. Policyt€_ C �-2CJUcCs Rad s. 2 ?1� da Tent F� Duration Siding: # of Squares . _ _ WORK TO BE PERFORMED (Fire Retardant Certificate attached?) Replacement windows: # Roofing: of Squares (❑) Remove existing* (max. 2 layers) /Old Kings Highway/Historic Dist. placing like for like °The debris will be disposed of at: f A R, iF 0 0 ) } Location of Facility Wood Stove 0 Replacement doors: # insulationil Pool fencing 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 revocation of my license and for wsecution under M.G.L. Ch. 268, Section 1. Applicant's Signature: ���� Date: Owners Signature (or attachment Date: Approved By. Building Official (or EMAIL ADDRESS: Date: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft. of Wetlands: Yes No Yes No ;;9 Sherman, Lisa From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net> Sent: Thursday, June 2, 2022 7:50 PM To: Sherman, Lisa Subject: Re: 22-EB068 35 Route 6A 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. Good to go. I approve. Richard On 06/02/2022 3:04 PM Sherman, Lisa <Isherman@yarmouth.ma.us> wrote: Hi Richard, APPROVED JUN 0 2 2022 YARMOUTH OLD KING'S HIGHWAY Request to replace some cedar shingles on the back of 35 Route 6A. The contractor estimates about 25% of the house, all in the back. Currently is cedar shingles, so like for like. 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 1 The Commonwealth of Massachusetts ICEIVED Department oflndustrialAccidents APPROVED > I Congress Street, Suite 104 JUN 0 2 2022 Boston, MA 02114-2017 JUN 0 2 2022 5.•`' �t 4 www.mass.gov/dia �'o'pcpgio Insurance Affidavit: B uild ers/Contra cto rs/Electri[9MLP4TU �1fGHWAY TO BE FILED WITH THE PERMITTING Atl'rHORITY. Api3licant Information Please Print Legibly Name (Business/Organization/Individual): ;Y�I i l ' i' % I Address: % C [- cU `� -. City/State/Zip:7 a x I �t �-` ? / / N !1 / Phone #: 5 j Are you an employer? Check the appropriate box- ], D ox:1.D am a employer with employees (full and/or part-time).* 2-F-1 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. []1 am a homeowner doing all work myself. [No worker' comp. insurance required.] t 4.❑ I am a haa=wner and will be hiring contractors to conduct all work on my property. I will ensure that all contactors either have workers' compensation insurance or are sole proprietors with no employees. 5.E] 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, y 1(4), and we have no employees. [No workers' comp. insurance required] Type of project (required): 7. [] New construction 8. LJ Remodeling 9. ❑ Demolition IOEJ Building addition I I- Electrical repairs or additions 12. [jPlumbing repairs or additions 13-E] Roof repairs 14. []Other •Any applicant that checks box ig I must also fill out the section below showing their workers' compensation policy information- Homeowners nformationHomeowners 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:.. - ls{- 1 C X_' Policy # or Self -ins. Lie. 4: �. �J ] �, 5 " .� Expiration Date: .3 Job Site Address:�, City/State/Zip:_? ,lC: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGI. 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 �� 21 Phone #: Official use only. Do not write in this area, to be completed by city or town offcciaL City or Town: Permitll,icense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #- Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Const+�isor CS-10407661-pires: 09107/2023 MARK M MUJO-14 ^° 7 CONNEMARA WEST YARM01 NOTJ.t+ris`ia°� Commissioner d6 h-. i�tmc a RECEIVE® JUN 0 2 2022 0 APPROVE® JUN 0 2 2022 _ YARMOUTH r