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Home My WebLink AboutNO PERMIT NEEDED n6perrn% rRE/VED iE Office Use only ;r �5 fey �iyi-l�. MAR 0 2023 Pent#._...._ Amount �. MrTTht BUILDING DEPARTMENT \°TM nY — — Permit expires 180 days from (.37'.1::::' ' ,gC'"` issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I I 1 r r'j"te, Co tke-- o d ; SUIT Vau" Tl ASSESSOR' INFORMATION: Map: Parcel: OWNER Ch ecl J r�)fi _ +./_i r!.° Cl7 t�`! l�f�' .s(�p —02�I— ')f NAML PRESENT I ADDRESS TEL. # CONTRA( l'CR:t ,fro). 17t4 l i' -' AD.&las-4, te,Seel dr,c);ei• 423-37 -1 y-7a2-73ka.. NAME om0 j i„Lc, MAILING ADDRESS TEL.# Residential 0 Commercial 7✓� �r Est.Cost of Construction$ I �I ' home Improvement Contractor Lie.# 1 9Y'3�5 Construction Supervisor Lic.# CS "Qg. / Workman "r ,mpensation Insurance: (check one) El 1 i uu the homeowner 0 i am the sole proprietor XI have Worker's Compensation Insurance Insurance Company Name: A T 0 Mt i. J...L,(S, ArAcii Worker's Comp.Policy# W M Z"FDO—WO . .J-df}3.4. WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove Ell Siding: n 01 Squares Replacement windows: # Replacement doors: # Roofing: i; of Squares ( ) Remove existing* (max.2 layers) Insulation 1 I Old Kings Highway/Historic Dist. t Replacing like for like Pool fencing I I ePie-r-j yr 'i .{'C!G Lk_ ,� *The dehri�,v,i1Ihe disposed ofat: llAf ltJLL_� (Jv SO��(�5 reueo Locatio of Facility et.)rri tor 0 Oa m A./1 I declare under p nalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief I understand that any Ise answer(s) will be just u,.,:for denial or revocation of my license andfor prosecution ender M.G.L.Ch.268,Section I. Applicant ` _i;il ire: t Date: SA��. Owners Signal re(or attachment) Date: Approved By Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District Yes No Flood Plain Zone: :' Yes No ,(� Water Resource Protection District: Within 100 II.of Wetlands: `,,/\� ' Yes No .1 Yes No rw,l Office Use Only i o`l, 1 Pennitfl E Permit e.kptres ISO days from issue&cc EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-22311 Ext. 1261 ('O\SIR: r ,IONS ADDRESS _ 11 i v rti .Co 104 IC t , _�. ,. .. ULA1, yam.-m1/14-71 ASSFSr•t NI t. R iA'rlO, ._. I`tp' . Parcel: I t)WN'i ,t Ch e cAi�--f� 1 i t 1 of 14 t � a Pitt SI'tI vDIHtt S'+ — in �ii� J n ,r� rr S CON.i R r• t (c I Jjir",b 19t, l ti'd w..-_. ... _P U I ,*.1.5L. C _5e 1 , J c �lnv>t f },.l.C. .IF II IN ntIlt}:SS TFC s , ....___. XResiric,€ QContmercial {� Est.Cost of Construction$ 6t 7 -� Home lutho„ anent Contractor Lie.if I g 4 � cc., —0 3/ 3'•�✓ Construction Supervisor Lie.# CS W'inL.,;t.rs, ,npeo-anon Insurance: (check tn., G 'tc i' 'tatemtnet Q I am the<.rn, plow'ictvr A I hate Workers Compensation Insurance Instil-wk. min' '..a me: A r VI H ti 'Uct;i L.£lSc 144141 C 1 Worker's Comp.Polic)*'. Pi 2—5'00 7S'ildS/a)71,410-2-A WORK TO BE PERFORMED Tent J Duration ,__ (Fire Retardant Certificate attached?) Wood Stove Ell Siding: Squares .� Replacement windows: t Replacement doors: N Roofing: _ of Squares (j ) Retnooeexisting*(max.2 layers) Insulation El , j.._._I _t r . Kings Highway/Historic Dist. IN) Replacing like for like Pool fencing �t�/ 111 ell yerie- lr,en_ �..__ `"rh,J=:^ s'-'e dr,p,ksed of Et d7.: ...: 0 L �+. f�a..' Incatint of Facility i dcet:nc u ,-aI,c ;:f per}urt no the statements h:rs,t,contained are true;iid correct to the hest of tat knowledge anti belief I understand that ant take anstter s 3. ttrl'I1,'lu, 01 ri:nt.tl or rcv,r,_Jt4r*n r f my keens,xi,n= tar isurs,cutinn under!l tt I Ch 2MK,Section i Ott nett sip,..• e€ r :,ttachnientt _ (� . ._ Date:_... -ta..1�__ ___ ....._ Date ri odtltng C}iticral A,r designee) wilt Af511itt-tik Zoning District IIistaric.tl 1 ; ,:, N't, No l(fend Plain Zany. Ye... No Water Itcsoht , ,'<ttit.tt:`nr,I)i:.irt,i'. t "rilon Irk)It ,t1 W"ettanda; 't 'tit) ye No i ,per The Commonwealth of Massachusetts =_ 3 Department of Industrial Accidents 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): �/raw, jj A).;1(�v% v' ,nd A kC Address: p Q, gd( .ZS� City/State/Zip: K‘S ► 7 -A, i ; a,57-g Phone#: 7).-.1-73�'� Are you an employer?Check the appropriate box: Type of project(required): 1. am a er:pioyer with 3/ employees(full and/or part-time).* 7. D New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capa:ity.[No workers'comp.insurance required.] 8. ❑Remodeling 3.nI am homeowner doing all work myself. t 9. Cl Demolition y [No workers'comp. insurance required.] 4.nI am a 1-min myProPertY•eowner and will be hiring contractors to conduct all work on I will 10 Q Building addition ensure th,t all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions prop ieuxs with no employees. 12.❑Plumbing repairs or additions 5.01 am age<ueral contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.nWe are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other K Lt 152,§1(4),and we have no employees.[No workers'comp.insurance required.] I *Any applicant that checks box 41 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 Liar::heck this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If She 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: L' v 4,.P --/-71 st e..t Policy#or Sei`ins. Lic.#: h'HZ—ereza- -62)ef,11••v 4 Expiration Date: � � a2/3 Job Site Aa: :sss: //%vf e 61,y, /7,1 S mry"rx-- City/State/Zip: Attach a cop) 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-ycr 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 th:_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 a penalties of perju that the information provided above is true and correct. Signature: Date: -+�?/,? Phone#: _ - 71'' 7 Official us 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 I'. ;-son: Phone#: