HomeMy WebLinkAboutBLD-22-007415 O�.Y`�R C 9 1�"� Office Use Only
$ 1'` C f Zt/ Z ,Permit# /�,/}
O . I,'Ig _ y Amount.67(tf
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Mromco''4, x i Permit expires 180 days from
i issue date
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EXPRESS BUILDING PERMIT APPLICAT E D E 1 V E D
TOWN OF YARMOUTH
Yarmouth Building Department JUN 2 4 2022
1146 Route 28 _ _
South Yarmouth, MA 02664 BUILDING DEPARTMENT
(508) 398-2231 Ext. 1261 By
CONSTRUCTION ADDRESS:c23 CA() tieS / it ,4 ase_, r\ . WP / ya� 7 \ M ic A-
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ASSESSOR'S INFORMATION:
fMap: Parcel: Cj�7g p
- OWNER: J,id4 A Puree/ / / - '9 4ss7
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
1I esidential ❑Commercial Est. Cost of Construction$ L59D,.6 t
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's�/ Compensation Insurance: (check one)
V I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows: # Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like R,lel•fencing et` - pactiaatic
zoning ptu pd ew
/The debris will be disposed of at: siN /Pt
Location of Facility
I declare under penalties of perjury that the 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date:
V Owners Signature(or attachme aP�C(/l C. _ Date:
Approved By: ~_,,. Date: — sy—41,
Building Offici ( r designee) EMAIL ADDRESS:
e0n.feri/a) 20L Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: `l Yes ❑ No
iiiii DO
Water Resource Protection District: Within 100 ft.of Wetlands:
ettialiteet 0 Yes 0 No 0 Yes 01 No
IMP
• The Commonwealth of Massachusetts
*W, ►� /, Department of Industrial Accidents
'",/11= 1 Congress Street, Suite 100
,_ <' Boston, MA 02114-2017
5,.�'� www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
✓Address:c;, 3 cienweS' f 2 mka se_. RIC
City/State/Zip://,00T /1-flmbu-( IV) Phone #: ('7!`V9O- te 5 3 7
Are you an employer?Check the appropriate box: Type of project(required):
l.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
` 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑ Building addition
4.21 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.❑Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5.0 I am a general 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.*
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 verification.
'/I do hereby cer ' under th ins and penalties of perjury that the information provided above is true and correct.
v Stanatur . �[.(/lC=C�C.0 Date: l� - 7 -aD,
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#:
s _
r .
CONSERVATION
" ; OFFICE
t" ¢ kgrant@Yarmouth.ma.us
Yarmouth Conservation Commission
Administrative Review Yar 'cQmmconser,, }
Ss/on on
Applicant Information: Jirn;?i/-'cI'/
22Name: //J)et/i ' fi
Mailing Addressa?5 13/ tr.', ./i/f)L' ,b' j t". eIfn5fiei 1 i +` ♦ ; i►
Phone: 9 / I 9V '(06 3 Email: ftifC //S t l
! * J�11� < �. Yl
Signature: Xak,
Location of Work:023 (M)€ec I?ii l CA s 41 10 eS , //y' ouW ! ,
Street Name
and Number
Please Note:By submitting this application the applicant grants permission to the Conservation Office to enter the location to conduct a site visit(if needed).
Detailed Description and Reason for Proposed Work: �)
7.1
sic k- . '. P--- ..
Closest Distance to Resource Area: I -LC)0 d. 7-6
Proposed Start Date: t . j 12 e/1ztx.
Company to do Work:
Name:
Address:
Phone: Email:
Administrative Approval: a —r-b' 1 L a c K / /vG
i` � e Av.Jt.:�
This approval is valid for one year. This Approval does not grant any property
P �Y rights or any exclusive privileges;it does not
authorize any injury to private
property or invasion of property.
Yarmouth Conservation Commission• 1146 Route 28,South Yarmouth,MA 02664•(508)398-2231 •Ext 1288
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971972 - 53 7--
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