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HomeMy WebLinkAboutBLD-23-006015 M0":�esr�Ilse only I ",-- .,,,,,.,-'. i.-4't„,)t 3 /c11/71 L ,e,t4i. ,, j 0. :C.411';.lit M AY oar , a BUILDING DEPA' w _ RTMENT "„'�0.0 lgtt ant - i , bi,/p -„23 -6610415 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS; 15 Barnacle Road ASSESSOR'S INFORMATION: Map: 35510 Parcel: 190 OWNER: Nicholas Papakyrikos 16 Birchwood Road Needham MA 02492 781-888-4519 NAME PRESENT ADDRESS TEL. # CONTRACTOR: N/A NAME MAILING ADDRESS TEL# ElResidential ❑Commercial Est.Cost of Construction$4000.00 Home Improvement Contractor Lic.# Construction Supervisor Lic.it Worinriatt's Compensation Insurance: (check one) El tam the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent ;l Duration (Fire Retardant Certificate attached?) Wood Stove ❑ Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 19 (0)Remove existing*(max.2 layers) Insulation ri 121 Old Kings Highway/Historic Dist. t�Replacing like for like Pool fencing ❑ appi van y/a7A_3 *The dttiris will be disposed ofat: Town Of Yarmouth Disposal Area 606 Forest Rd Yarmouth MA 02673 Location of Facility I declare under penalties of perjury that the statements herein contained are true and-correct t©the best of my knowledge and,belief. I understand that any false answer(S) will be just cause for denial or revocation of yl' " se and p o der M.G.L.Ch.268,Section I. Applicant's signature: � `�`` Date: � � L'.. / Dater /72- vZ� owners slgnatu;a t;or attach' eat)... .-- Approved By: Date: —/ '2_3 Building Official(or ' EMAIL ADDRE Zoning District: Historical District: 0 Yes D No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts =_ i==.4l, Department of Industrial Accidents Imistff" 1 Congress Street,Suite 100 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): Nicholas Papakyrikos Address: 16 Birchwood Road City/State/Zip:Needham MA 02492 phone#: 781-888-4519 Are you an employer?Check the appropriate box: Type of project(required): 1.1=II am a employer with employees(full and/or part-time).* 7. ❑New construction 2.11)am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.l I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 El Building addition 4.0I am a homeowner and will 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.QElectrical repairs or additions proprietors with no employees. 12.['Plumbing repairs or additions 5.0I 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 6.1-3we are a corporation and its officers have exercised their right of exemption per MGL c. 14.DOther 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. t•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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 7,f(- y 7 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#: Hi We intend to live in the home year round Thank You Fallon, Rosa From: Sherman, Lisa Sent: Thursday, April 27, 2023 3:19 PM To: Fallon, Rosa Cr npapakyrikos . ,.'I.com; Sherman, Lisa Subject: tE 'e for Like Weathered Wood Roof replacement Hi Rosa, OK for the new roof at 15 Barnacle Road. Replacing like for like with Weathered Wood color asphalt shingles. Please let me know if you have any questions. Thanks Rosa, Lisa Lisa Sherman Town of Yarmouth Administrator, Old King's Highway Historic District and Yarmouth Historical Commission 508-398-2231, ext. 1292 Isherman@yarmouth.ma.us 1