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Home My WebLink AboutBLD-23-006032 e a a tL of 5/g4,23 , 6.1'Y44` Office Use Only '5 Permit �—J� Ou ' H. yAmount ,CD L MATT 1� ! �.' ? 7 ,Permit expires 180 days from ^:.;; „ 1 issue date _ /3 D-023 b 2_ EXPRESS BUILDING PERMIT APPLICA �C E I V E D TOWN OF YARMOUTH Yarmouth Building Department MAY G 2 2623 1146 Route 28 --- — South Yarmouth, MA 02664 a u I EN T (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 87 / 1 • t(kcY1 SiTLQl-- ,747 &A ASSESSOR'S INFORMATION: Map: Parcel: OWNER: c7o2-a.(J rQ.S e- siv\o�S ii- Yet(- Poc+ .5V - 73G -O3 l'-( NAME tt I� PRESENT ADDRESS TEL. # CONTRACTOR: P0.-�;UL. ja[.ebb S PO. 6 Ox 31-t`( Y-Pet- -7 7y- 3S3-&8sa NAME MAILING ADDRESS TEL.# rP sidential e kOCommercial QQ Est.Cost of Construction$ 6p1 t�✓ Home Improvement Contractor Lic.# ) (p cjD S Construction Supervisor Lic.# CS—o S i OM 0 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: Worker's Comp.Policy# WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares '7 Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I Old Kings Highway/Historic Dist. i ill E Replacing like for like Pool fencing n w cve C.eci. fr vitot, cjici . 41AA. Si?)2,3 *The debris will be disposed of at: rm Q Location of Facility I declare under penalties of perjury.r at th 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 re atio• of"cense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: #�� Date: Owners Signature(or attachment) d'' 42/ 6 Date: Approved By: Date: r-2- Building Official(or igne EMAIL ADD S: Zoning District: Historical District: El Yes ❑ No Flood Plain Zone: Il Yes L- No Water Resource Protection District: Within 100 ft.of Wetlands: LI Yes El No L Yes n No _ The Commonwealth of Massachusetts e. 1_ L Department of Industrial Accidents �C. -10.1= 1 Congress Street, Suite 100 Y � c_tif- Boston, MA 02114-2017 ,.� wwx.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): eakc1 aCt-told f Address: P.O. 60x 3Ljy City/State/Zip: tar at,IPrrt / 0444 0.\-0 7 Phone#: -77K -3S7-62 es- . Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with employees(full and/or part-time).* 7. El New construction 2 E l I am a sole proprietor or partnership and have no employees working for me in $. Remodeling y capacity.[No workers'comp.insurance required.] /�` 3.0i am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. El Demolition 10 0 Building addition 4.0I am a homeowner and wdI be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.111 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.1=1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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.Lie.#: 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 i. the ,ains and penalties of perjury that the information provided above is true and correct. Signature: /jig/� Date: `I c› dtai Phone#: 77q-3 -Coe 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROV��p��, ;CONTRACTOR d PEt t7o'.�t:a• i ..l 424 -PATRICK JACOBS DIB/A P.JACOBS CUSTOM'1 �RN AND REMODELING PATRICK JACOBS 1. /! 28 WHITTER DR. (' '4 DENNIS,MA 02638 Undersecretary Commonwealth of Massachusetts Division of Occupational Licensure `-% Board of Building R ulations and Standards Cons iiSnrS ivisor CS-081040 Ecpires:04/04/2024 PATRICK H COBS '*; + . 28 WHITTIEIORIVEt 1.4 , DENNIS MA 6838 f ; =% Commissioner Cada t7tin, Internal March 24,2023 Town of Yarmouth, MA To Whom it May Concern, With this letter, I grant permission to P.Jacobs Custom Carpentry& Remodeling from Yarmouth to perform renovations on my home at 879 Route 6A.These renovations include remodeling a bathroom and replacing white cedar shingles on the exterior. ulcer Joseph Tauras 879 Route 6A Yarmouth Port, MA 02675 Mobile:774-276-1036