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Home My WebLink AboutBLD-23-005812 Lin 4//2023 Office Use Only } nl� C, Permit# L��J F-�7i '7y o ?� y Amount 71(.// purr n s Permit expires 180 days from issue date 8 Ln -02.3-o 65g)2- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 ,,w South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 APR 19 2023 109 Notthingham Drive - CONSTRUCTION ADDRESS: BUILDING DEPARTMENT By ASSESSOR'S INFORMATION: Map: 150 Parcel: 29 OWNER: Steve Graziano NAME PRESENT ADDRESS TEL. # CONTRACTOR: FLYNN High Per 146 Hokum Rock Road, Del 7742689370 ✓ NAME MAILING ADDRESS TEL.# ElResidential 0 Commercial Est.Cost of Construction$25000 Home Improvement Contractor Lic.# 147951 Construction Supervisor Lic.#CS-098040 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 1 have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent U Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 25 Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation L l (a' I Old Kings Highway/Historic Dist. CI)Replacing like for like Pool fencing El tLs t *The debris will be disposed of at: Town Transfer Sration Yarmouth or S&J Exco Dennis Location of Facility I declare under penalties of perju the state nts 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� to of'/icense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: "/ Date: I 7/Z-3 Owners Signatu or attachment) Ale Date:Approved By: Alii�� rlagle Date: 7- /7 �a 3 Building Official(or d .'nee , EMAIL ADDR:i Zoning District: Historical District: LI Yes I No Flood Plain Zone: I- Yes C No • Water Resource Protection District: Within 100 ft.of Wetlands: i 1 Yes 11 No L1 Yes U No Permit Authorization Form i 6'f c..t`C_ et -z(a ( am the Owner/Trustee of the property located at 1 o Ho 1r/ and hereby authorize FLYNN High Performance, i forapermit to �,[,� '�- � 1 cs- /It . LLCtoappy .. . 77 , a /‹.3 Owner Signature Date 4 jm = { •\c,z pO� z _u) c = _= K „ 3°C s moro73 37 O -:.. O n i z = LT A "% 0 4 cn C`n P z7 • n 3 wr• -In 12 g w 3 car - 3 ZW� p § m 0= 1 p' z=3 p m c0i & = G 3'C �,'< QQ CD ' D 3 0p3 vi 3 -.4 z C 7 DI 0 0 �..a0.cn `''G. JJ .,. 4 7 N ¢ O N� ff ,,cV. a Ot M ..oiio rm 7 s�n"� o -+ - vs.to ns = �c o Q �N�' o ° w` ` `a in J.O Q �cz mo 0 y p c c 4 a m ::.3 co F tl C ice/ ,: The Commonwealth of Massachusetts 41M. ►=er/ Department of Industrial Accidents 1 Congress Street,Suite 100 Alit. Boston, MA 02114-2017 }��• .t www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Anolicant Information Please Print Legibly Name (Business/Organization/Individual): 1(-vii/1 6- `( Q—C.116/Yril�C�✓ Address: _ �,�6' :� �L _J 02-4 City/State/Zip: !/IAILi WL 02 hone#: 7 7 gt < 3 70 Are you an employer?Check the appropriate box: Type of project(required): 1.01 ar!,,ernployer with employees(full and/or part-time).* 7. New construction 2 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] $• ❑Remodeling 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.1D1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Ej Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet12.QPlumbing repairs or additions These sub-contractors have employees and have workers'comp.insuranc e.t 13. oof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c, 14. Other � 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 verifica I do hereby c and the pains and penalties of perjury that the information provided above is true and correct, Signature: Date: #//j V2--3 Phone#: 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#: