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Home My WebLink AboutBLD-23-002674 •YqR //—/S L- Office Use Only ` O Permit# S� C O . - H Amoun( j 2.OD 4""1t1P c'd Permit expires 180 days from issue date /3/.4)--02 3 -QU Flo 74 f EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department LIJ1 1146 Route 28 1 South Yarmouth, MA 026645 2022 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 923 Rt 6A Yamiiuth Port Sunflower Market Place BuildinAA- --'--- ASSESSOR'S INFORMATION: Map: 143 Parcel: 111 OWNER: Chapter Two LLC PO Box 206 Yarmouth Port 508 423-9311 NAME PRESENT ADDRESS TEL. # CONTRACTOR: James N Basler Box 366 Yarmouth Port 508 423-9311 NAME MAILING ADDRESS TEL.# ❑Residential /Commercial Est.Cost of Construction$ $2,000 Home Improvement Contractor Lic.# 181241 Construction Supervisor Lic.# 012929 Workman's Compensation Insurance:f check one) C I am the homeowner y I am the sole proprietor 1/I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 1 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: Nauset Disposal Location of Facility I declare under penalties of erjury 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 denia r revo anon o ny license for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 11/15/2022 Owners Signature(or attac ment) Date: 11/15/2022 Approved By: Date: Building Offici de ' e) EMAIL AD S: jbasler@comcast.net Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No . Yes No Commonwealth of Massachusetts Iiir Division of Occupational Licensure Board of Building Re ulations and Standards ConsttbkranrSvisor CS-012929 w R , a' i �cpires:03/08/2024 JAMES N BALE ' ; 1 ` PO BOX 366 z sfr YARMOUTH i i:• �. lib • ilhis ,0� aGLVditJ Ait ' Commissioner VIo�/• K. rr wL. •_. ......... ....... . Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:individual Registration Expiration' • 181241 03/12/2023 JAMES N.BASLER JAMES N.BASLER 42 VESPER LANE �...,(4 ,C ..4 i BOX 366 ilhdersecretary YARMOUTHPOR'?,MA 02675 *4a / , pa . 7 The Commonwealth of Massachusetts Department of Industrial Accidents r 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,r �•'y 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): James N Basler Address: Box 366 City/State/Zip: Yarmouth Port MA 02675 Phone #: 508 423-9311 Are you an employer?Check the appropriate box: Type of project(required): l 'l am a employer with 0 employees(full and/or part-time).* 7. New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8, C Remodeling any capacity.[No workers'comp. insurance required.] 3.- 1 am a homeowner doing all work myself. [No workers'comp. insurance required.]t g C Demolition 4.]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [] Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.`e I am a general contractor and I have hired the sub-contractors listed on the attached sheet. li.C Roof repairs 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. 14. 'Other window 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. 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: Chubb 6S62UB-9F65611-9-21 4/6/2023#or Self-ins. Lic.#: Expiration Date: Job Site Address: 923 Rt 6A Yarmouth Port MA 02675 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, §25.A 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. Signature: Date: November 15, 2022 Phone#: 508 423-9311 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#: i a: ..,� TOWN OF YARMOUTH RECEI t) 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 a Telephone (508) 398-2231 Ext. 1292—Fax (508) 398-0836 JUN 0 9 20220LD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE (AMWIUUIr, OLD hINQS HIOHWA'' 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: 923 Route 6A Yarmouth Port Map/Lot# 143/111 Owner(s): Chapter Two LLC James N Basler Manager Phone#:508 423-9311 All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: Box 206 Yarmouth Port MA 02675 Year built: 1984 Email: jbasler@comcast.net Preferred notification method: Phone Email James Basler 508 423-9311 Agent/Contractor: Phone#: Box 366 Yarmouth Port MA 02675 Mailing Address: jbasler@comcast.net Email: Preferred notification method: Phone Li Email Description of Proposed Work(Additional pages may be attached if necessary): Add a window to the second floor. Window will match existing windows. Signed(Owner or agent): 4 Date: 6/1/2022 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: /Approved i monk Date: /c'4'7) • _Approved with changes rrRO en Amount_ v�O CI) Reason for denial: -t � ' f ' f Cash/CK#: tJ r YARMOUTH Rcvd by: G;S' e .9 • ► _r Date Signed:_20/2,2 Signed: Uk\ed oft i I APPLICATION#: 12— -OW V5 2017