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Home My WebLink AboutBLD-23-003381 r GDCov/t() IU S 'Amount �(/a L —2 d DEC 19 2022 1 ¢ }Permit expires 180 days from 1 ._ _ l issue date BUILDING DEPARTMENT -023 _pa33g1 By _ EXPRESS BUILDI IT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 V/ (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: Z. 1 C rJ lJ I=- .- A ( ...L, 0-,'D V ASSESSOR'S INFORMATION: Map: Parcel: /OWNER: FNI 4 t')0 1 l� L=N i. 5b I b ) 3 - 3 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# l Kesidential ❑Commercial Est.Cost of Construction$, 5, 000 . (5D Home Improvement Contractor Lie.# Construction Supervisor Lic.# Work 's Compensation Insurance: (check one) meI am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.r ,d# WORK TO BE PERFORM' Tent Duration (Fire Retardant Certificate attaches'".) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # /Roofing: #of Squares 1 MO ( )Remove existing* (max.2 layers) Insulation . Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing \/The debris will be disposed of at: ci I -r.eA 5 U Y . 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 oflny license and for prosecution under M.G.L.Ch.268,Section 1. ✓ Applicant's Signature: APB- Date: Owners Signature(or attachment) / Date: 4a//-I/A%7 Approved By: v Date: /.� -/! �. Building 0 ial designee) E DRESS: Zoning District: Historical District: 0 Yes 0 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 Department of Industrial Accidents -Wrtmoms 'A'._ 1 Congress Street, Suite 100 IMAMS1�_ Boston, MA 02114-2017 5.•` 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): / Address: 2( (" N rc A R I City/State/Zip: 5,0 -TL& �'0IKA�.cmw r) 024 1 Phone #: ? O I c.i —c Are you an employer?Check the appropriate box: Type of project(required): l.zl I am a employer with employees(full and/or part-time).* 7. New construction 2.❑I a sole proprietor or partnershieand have no employees working for me in 8. ❑ Remodeling capacity. [No workers'comp.insurance required.] _ 73. I am a homeowner doing all work myself. [No workers'comp.insurance required.] 9. _ Demolition I am a homeowner and will be hiring contractors to conduct all work on10 Building❑ addition 4. ❑ 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[I]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. 14.7 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 certify under the pains and penalties of perjury that the information provided above is true'and correct. /Signathre: 17* Date: / 2_1 l / / 2C 22 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#: Bk 35539 Pg124 #61254 12-13-2022 @ 01: 19p NOT NOT AN AN OFFICIAL OFFICIAL COPY COPY NOT NOT AN AN OFFICIAL OFFICIAL COPY COPY QUITCLAIM DEED I, DARRIN E. DUTY,being married, of 91 Capt York Road,South Yarmouth, MA 02664, for consideration paid of THREE HUNDRED TWENTY-NINE THOUSAND DOLLARS AND NO/100 ($329,000.00) grant to RICARDO PENA PORTILLO, Individually, of 21 Frank Baker Road,South Yarmouth, MA 02664 c) WITH QUITCLAIM COVENANTS, � Q The land together with buildings thereon, situated in Yarmouth(South),Barnstable. c pa I., Being Lot 49 as shown on plan entitled "Plan of Land in South Yarmouth, Mass. for Stratton Building Corp. of Cape Cod Scale 1" = 30' February 1969 Barnstable County Survey Consultants, Inc. 608 Main Street, West Yarmouth, Mass." recorded with Barnstable County Registry of Deeds in Plan Book 242, Page 19. The above described premises are conveyed subject to and with the benefit of all rights, a.) restrictions and easements insofar as the same are in full force and applicable. Grantor,hereby release any and all homestead rights to the within premises, whether created by declaration or operation of law, and further states under the pains and penalties of perjury that there are no other individuals entitled to homestead rights to the property being conveyed herein. For Grantor's title see deed recorded in the Barnstable County Registry of Deeds at Book 26970, Page 324. Property Address:21 Frank Baker Road, South Yarmouth,MA 02664 MASSACHUSETTS STATE EXCISE TAX BARNSTABLE COUNTY EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS BARNSTABLE COUNTY REGISTRY OF DEEDS Date: 12-13-2022 @ 01:19pm Date: 12-13-2022 @ 01:19pm Ct1#: 437 Doc#: 61254 Ct1#: 437 Doc#: 61254 Fee: $1,125.18 Cons: $329,000.00 Fee: $1,006.74 Cons: $329,000.00 Bk 35539 Pg125 #61254 N O T NOT AN AN OFFICIA OFFICIAL C O P Y ^N C O P Y WITNESS my hand and seal this `' day of jc..•jcaii 2022. NOT NOT AN OFFICI A AL COPY CO _Y DARRIN E. DUT COMMONWEALTHrr�� OF MASSACHUSEITS r � s �� County of rl n1 {+-1 v On this .)0 day of 'v '1 c"2022, before me, the undersigned notary public, personally appeared,DARRIN E DUTY 0 personally known to me,or El proved to me through satisfactory evidence of identification,which was driver's license 0 (other:) to be the person(s) whose name(s) are signed on the preceding or attached document, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his knowledge and belief, and acknowledged the foregoing to be his free act and deed for its stated purpose. r Notary Pu ,' is !, o ';'v: F`:3, My Commission Expires: ' ,, 1(�/7C)Z''- ckc Sr 1 i [SEAL] ;r " s• EX�tk- : .j� OiZ . Bk 35539 Pg126 #61254 • WITNESS my hand and sgal1his ,' day of ��1r �� 022. OFFICIAL OFFICIAL COPY COPY NOT T AN OFFICIAL HEA OEF 9 IA COPY COPY COMMONWEALTH OF MASSACHUSEnS County of C;)v)-r--,.. ns-V7ki.c On this day of ‘,\CL•r'm ,e,(2022, before me, the undersigned notary public, personally appeared,HEATHER DUTY 0 personally known to me, or El proved to me through satisfactory evidence of identification,which was driver's license 0 (other:) to be the person(s) whose name(s) are signed on the preceding or attached document, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of her knowledge and belief, and acknowledged the foregoing to be her free act and deed for its stated purpose. -5i/4,4d .511 . Notary Pt blic '" .: My Commission Expires:,) to/ %t-G' [SEAL] ` r' F JOHN F. MEADE, REGISTER BARNSTABLE COUNTY REGISTRY OF DEEDS RECEIVED & RECORDED ELECTRONICALLY