HomeMy WebLinkAboutBLD-23-005556 . A pi o ika
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�:�; :,Permit expires 180 days from
issue date
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EXPRESS BUILDING
PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department R E V E
1146 Route 28 "' . �"_.�m.__._
South Yarmouth, MA 02664 MAR 3 1 2023
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: \ CC.0 `l_.( '\t�`)sc LaA� BUILDING DEPARTMENT
ASSESSOR'S INFORMATION:
I Map: X I Parcel: X''''
I
OWNER: 5 . AL \L t(\'nCr CLYX\C 0II--ko4'
I�
NAME PRESENT ADDRESS ����
CONTRACTOR: (DC_C t tS k- tY\ \x IS LPL 1Sci ( p �eSlCe `� TEL -) q u7- ����
NAME \l�r1J � 5wo l
n G AD TEL.#
0 L 1.) UY\Dd\TRESSS iG O'ILL b
Residential 0 Commercial Est.Cost of Construction$ s !ODD
Home Improvement Contractor Lie.# ' () l-1—1 Construction Supervisor Lic.# UkaLt.th
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 13 I have Worker's Compensation Insurance
Insurance Company Name: ,`r A\I��t,`C 5 Worker's Comp.Policy 1 -1(1 6-VI Qy LS r- 1-11
WORK TO BE PERFORMED
Tent ri Duration (Fire Retardant Certificate attached?) Wood Stove l l
Siding: #of Squares Replacement windows:# Replacement doors: # a
Roofin #of Squares (❑)Remove existing*(max.2 layers)iv
Insulation I I
Old Kin Highway/Historic n�p�y� g y/Htstortc Dist. �Replacing like for like Pool fencing I I
*The debris will be lisposed of at: k
Location of Facility
I declare under penalties of perjury that the ments 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 revoc n my license and ,r prosec u.n undgyM.G.L.Ch.268,Section 1.
Applicant's Signature: •
a\-
Date:
Owners Signature(o ttachme
) Date:
Approved By: -76?"Building Official(.!'si e. EMAIL ADDRE Date:
/ S:
Zoning District:
Historical District: 13 Yes 2 No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes _l No 13 Yes E No
1 `
®� Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Re uiations and Standards
• Cons lonrSrvisor
CS-006646 spires: 11/15/2023
GLENN W CIii4FTS _,, c
72 COUNTRVCIRCLE, l7
SOUTH DENT j4 MA 60
A y�'
rot.Lvall 3-
4
Commissioner dada fi „
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Aff &Business Regulation
HOME IMPROVE +, ONTRACTOR
or •
e a e e,. e;,
• jT . _.T r_ •i
G.C.CUSTOM BUIL
17.1
GLENN W.CRAFTS vj
259 GT WESTERN RD x � t
S.DENNIS,MA 02660 y. .f , lw�i°rCG' 0Geork
Undersecretary
€ v
•
•
Date:04-03-23
To:Yarmouth Historical Committee
I Sandra Pickering give permission to GC Custom Builder§to replace two sliders located on the back of
my home.
Thank You.
Sandr4
a Pickering
71 Early Redberry Lane
Yarmouthport, Ma 02675
Ph.#508-362-1342
E-Mail:sandy,capecod@yahoo.com
The Commonwealth o
f Massachusetts
1.=_orl Department of IndustrialAccidents
C =?:�1i- y 1 Congress Street,Suite 100
`CE
Boston, MA D21I4-2017
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): C.3.C__
Address: r).S° () t.d SJ r .d
City/State/Zip: _tv, x5 ,c, 0).!.,\,) Phone#: 5U-.Y1A-Wi��
Are you an employer?Check the appropriate box:
Type of project(required):
1.®I am a employer with employees(full and/or part-time).*
2.01 am a sole proprietor or partnership and have no employees working for me in 8.7. ❑Remw construction
any capacity.[No workers'comp.insurance required.] Remodeling
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4.0 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'comp" v 1 ion insurance or are sole
proprietors with no employees. 11.❑Electrical repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.0R
2.QRoofr Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.* U'.0 Roof repairs
6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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
n.
t Homeowners who submit this affidavit indicating dry are doing all wok and then hire outside corm-actors roust ubmitt as ew 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. lithe sub-contractors have employees,they must provide their workers'comp.policy number.
I aiiz as employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: O U 5
Policy#or Self-ins.Lic.#:I P.a lb 13etc164 L, \ -13
Expiration Date:
Job Site Address:
/Zip:
Attach a copy of the workers' compensation policy declaration page(showing th/State a 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 un' e p and penalti
fPerjur1' at the information provided above is true and correct
Signature: QJ IA 4n
Date:
Phone#: 1SUY) r).1/4'qL SSSS
Official use only. Do not write in this area,to be completed b mp y crty or fawn offuxal.
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#:
V V/-.v
Alek
TRAVELERS J
NORi �."OMPa�pe+°?f�JN
EMPLOY
TYPE,FF INFORMATION ,G WC 71 e ( A)
POLICY NUMBER: (7PJUB-9904L51-4-23)
RENEWAL OF (7PJUB-9904L51-4-22)
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
A STOCK COMPANY
1. NCCI CO CODE: 13579
I dSUREL :
PRODUCER:
G. C. CUSTOM BUILDERS, INC.
INSURANCE AGCY CAPE COD
259 G - `:T WESTERN ROAD
SOUTH DENNIS MA Y,,61,0 P.O.BOX 1053
S.'NDWICH MA 02563• 1053
Insured is A CORPfR1`.r:,:" s:.
Other work places and identification numbers are >r own in th .sche uie--;) atkache'
2. The policy period is from 01-01-23 to 01-01-24 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
ANIMMINIE
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
1•=•1•1=1 item 3.A. The limits of our liability under Part Two are:
?== Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily H y by Disease: $
10 E. Employee
C. OTHER STz . L SUR.',NCE: Part Thre
r, -,ol?,., J'i?.; to ,:; state:,, ,'
COVERAGE RL a Y '' ?11ORSEMEN *: : ,1 03 iR
D. This policy includes these endorsements and schedules:
,. SEE LISTING OF ENDORSEMENTS — EXTENSION OF INFO PAGE
nommoo
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: t - ;9-22 wC
OFFICE: rY ^tc D', 701 STMA
PRODUCER: '=±'.JRANCE AGCY CAPE COT
?O652
yRogo?ip-71141 CLER‹
23..APR 3.2ot410:16 R.FC.
.. :,
to,-_,T:,,-,4, TOWN OF YARMOUTH
,,,, :''
1146 ROUTE 28,SOUTH YARMOUTH, MA 02664-4451
I REcFevi.-:4;:.,;if Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
OLO KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
ot o 1(1 'S H1(21-1wA Y '
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 le9ibiy;
Address of proposed work: 1 t US\ ‘s1 \;)C.,Cc Map/Lot
Owner(s): (aki‘ V tiltc‘ Cr Phone fr.SUo-TS krA4 M)
All applications met submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address ,,,)CLM. E.
Year built
Email
Preferred notification method Phone Email
. --
i , .,\
AuenVContractor,(;,L C,—LiS-kOtt\ 1).X.IA t ,,..LAS A AL Phone#S0f6:1ATts 16 is.st
Mailing Address: -N•Y‘.. G Celli ‘i. t..sktko.'\\. .(1. ('- o- ?.... ,no,
vvtv.1 Ulla
Email (iit.I.S14reittAlati'S' ' VitA, ts..A. Preferred notification method: Phone Email
t 1
\ e..3-y\CAL.0%.CY ‘ Ace -br \ A(t (S k e,c d.OU(';') t fX baLh Li 1 NkCJk..lAe
Signed(Owner or agent) , 1
Date,
.›. 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:
Dale:Amount
1/270)Rt-2)4)
CashiCK ft iq ii
Revd by L.,-, S.
Approved Approved with changes i al-r,e-7:1***Ned'
Reason for denial, 1.
-s,
Date Signed _911206 Signed: C Witt 011?( 1
2 3-r,oa
----- APPLICATION#:
VS 2017