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HomeMy WebLinkAboutBLD-23-003648 ea 4,- wD/kd O/1c_ it/77-4111-1 ,eitx_d'f i15i.L3 pay / 9D:�d e P1 Office Use Only O�• Permit# L—#071i, b 0 ' Amount 940 MATT M 3 �, Permit expires 180 days from /tissue date f G EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 JAN �4 2923 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: ey°80 Mid-Tech Drive, Unit 7, West Yarmouth ---- -- ASSESSOR'S INFORMATION: Map: 84 Parcel: 16/C 7 OWNER: Lewis, Jon Rober PO Box 1196, Barnstable, F 508-771-0303 NAME PRESENT ADDRESS TEL. # CONTRACTOR: OHC Inc. dba Th 30 Perseverance Way, Suit( 508-771-0303 NAME MAILING ADDRESS TEL.# ❑Residential p Commercial Est.Cost of Construction$ Jg 0 VO.Ot' Home Improvement Contractor Lic.# 100932 Construction Supervisor Lic.# CS-074034 Michael S Rockwell Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Travelers Worker's Comp.Policy# 7PJUB4759P3778 WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing [ X I Demolish existing drywall, insulation, nonstructural framing, plumbing and wiring. Remove flooring to subflooring. *The debris will be disposed of at: New Bedford Waste Systems, NBWS, Sandwich, MA 02563 Location of Facility I declare under penalties of perjury that the statements herein contained are true and corre o the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of m nse and for ution u d M.G .Ch.268,Section 1. Applicant's Signature: � •�/✓ . Date: 1/4/2023 Owners Signature(or attachment) (Attached) Date: Approved By: Date: r Q`0N Building Official(or designee) EMAIL ADDRESS: infothehouseco.com Zoning District: Historical District: Li Yes No Flood Plain Zone: 1 Yes I No Water Resource Protection District: Within 100 ft.of Wetlands: Yes .; No Yes I No The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations �;; �, 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): OHC Inc. dba The House Compnay Address: 30 Perseverance Way, Suite City/State/Zip: Hyannis, MA 02601 Phone#: 508-771-0303 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 2 4. I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ] ship and have no employees These sub-contractors have 8. Demolition and have workers' working for me in any capacity. employees9. Building addition [No workers' comp. insurance comp.insurance.+ required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs . insurance required.] c. 152,§1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 must also fill 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. :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: Travelers Property Cas Co of Policy#or Self-ins.Lie.#: 7PJUB4759P3778 7/21/2022 Expiration Date: Job Site Address: 80 Mid-Tech Drive, Unit 7 City/State/Zip: West Yarmouth, MA 02673 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 th ' and a f jury that the information provided above is true and correct Signature: OHK•/NC— Date: 10/17/2022 Phone#: 508-771-0303 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#: Owners Authorization Form Town of Dennis 685 Route 134 South Dennis, MA 02660 Please print or type Statement of ownership I, Jon R. Lewis own the property at 80 Mid Tech Drive, Unit 7 in West Yarmouth, MA 02673 Authorization and address I authorize, OHC Inc. dba The House Company, to represent me regarding all construction related work at 80 Mid Tech Drive in West Yarmouth, MA 02673, Name of Authorized Agent/Contr for Michael Rockwell, OHC Inc. dba The House Company, .dam Owners Signature Date /b// 7/ 2 vv Michael S. Rockwell, President OHC Inc dba The House Company 30 Perseverance Way, Suite 2 Hyannis, MA 02601 508-771-0303 info@thehouseco.com A separate letter from the owner with the above information and an original signature is acceptable.A faxed copy is acceptable from the issuance of the permit but the original must be forwarded prior to any inspection Phone number:508-760-6157 Fax number:508-394-6289 • Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards , Constuon fSrvisor CS-074034 E tpires: 07/27/2024 MICHAEL S I1OCKWELIr l. , 799 LUMBER.MILL RD MARSTONS Ppr,LLS MA 02648 r � Commissioner da.,