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HomeMy WebLinkAboutBLD-23-004691 ��.YAR �++ �^ a (,� � � c�r�U 1. I Office Use Only ` .0 RECEIVED L° - urn 2 I z3 I Z3 :I Permit# 'Amount 7S— MAT TA M [SEA �, °tw,,,,,E,.' $ FEB 23 2023 //f i�� / Permit expires 180 days from r ( {issue date BUILDING DEPARTMENT j y �� -00 ry I BY: V—---- cam- ""I EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 t South Yarmouth, MA 02664 MAR 06 2023 (508) 398-2231 Ext. 1261 w- -� ; LUItDI VG,;, DEPARTMENT CONSTRUCTION ADDRESS: 1 ( l h N ro F it (�OL W ' row rM o v.-1'�- ri • G 3 ASSESSOR'S INFORMATION: Map: Parcel: (� 'n �o3-�Sr151-73.�e OWNER: D i n0 Pon O I �Jn Qrpb�C �� �/ l`'C414 473 144 c--,y--),i NAME © PRESENT ADDRESS y TEL. # CONTRACTOR 1 n 0 1 V✓1 h I 0 I Fl h O K got L'. /�%+•M 014*x " 4- a& 7 3 `- 2 03 i'l y- 7 3? NAME MAILING ADDRESS TEL.# ,Residential ❑Commercial Est.Cost of Construction$ ll'UUV "'- Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED —Ce"Lr' P-th a e 7141 J-44 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: \ilaLr l3o -Tr a n S-1"C r' S+ar71 0-..' 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 revoca Dv. �n of my license and for prosecution under MGL.Ch.268,Section I. b .13 °2 6Applicant's Signature: FebOwners Signature(or attachment) L !_- Date: FDate: b 8-3, o't O a-3 Date: �-a 3 ).3 Approved By: �6 Building Official(off- ee) EMAIL ADDRESS: CAPt, ,rl b/0d�G ® giy 4,1 /. Coi,- Zoning District: Historical District: 0 Yes k No Flood Plain Zone: 0 Yes r No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes No 0 Yes ;-- No t, lot The Commonwealth of Massachusetts 7.7471=.. , Department of Industrial Accidents 1 Congress Street, Suite 100 sit . Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Dino POkr-i-oin f o Address: Pre aA. i/t- ntr- 'm 1 -j !12 - 0d , 7 • City/State/Zip: ba b 77 3 Phone #: 0 3 - .'/Y 2 3 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.�I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 ❑ Building addition 4.®I am a homeowner and will be hiring contractors to conduct all work on my property. I will r `ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp. insurance.; 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.g Other neLv P.-)tt�. 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: 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 and r the pains and penalties of perjury that the information provided above is true and correct. Signature: �- Date: 02—.2 ' 3 Phone#: al03-- 2I9— 733 P 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#: OWNER OF RECORD: DINO & LIZA PONTONIO PLAN OF LAND 30561E DEED CERTIFICATE 220317 ASSESSORS' MAP 58 PARCEL 375 LEGEND: CB CONCRETE BOUND C° FND FOUND `� Tall Sta uY H/T - WOOD HUB STAKE WITH TACK 95.09' 0 0 CB FND I -•T� ; Pi cket Fence 777777 N Q N n /Shed/ N • 38.0'± ■om' /////////////j 00 - [ C C�ma Existing 2 Bedroon - I 11 Dwelling,Top of / - I Foundation Tall Stake Set• I EL=51.9± / LI ' / S BH / / A - • • o H/T FND! `N Tall Stab 0 • S, 97.89' /}1 CB FND • • G:\AAlobs\9384.pontonio\dwg\9384.FNDN AS-BUILT.dwg J.M. O'REILLY & ASSOCIATES, INC. Professional Engineering & Surveying Services I CERTIFY THAT THE DWELLING SHOWN HEREON IS LOCATED AS IT EXISTS ON THE GROUND. DATE -"Zo mat P.L.S. • , h.; a O'REILLY NO.4a733 n �> ` " H/TSET To 0 0 0 • "TI )T27 cri =8,578sf± O o -0 0 0 6 � l0 0 I) 32.5'± 0_ BENCHMARK TOP OF CONCRETE BOUND . EL=50.7±(NAVD88 Datum) • II _ AS-BUILT PLOT PLAN • SHOWING EXISTING DWELLING ON - CB FND 1 FIN BROOK ROAD, WEST YARMOUTH, MA 02673 PREPARED FOR DINO & LIZA PONTONIO jiw!0 20 40 60 • SCALE 1"=201 JANUARY 20, 2023 / I / Drawn by:BSH JMO-9384 1573 Main Street, P.O. Box 1773 Brewster, MA 02631 (508)896-6601