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Home My WebLink AboutBLD-23-002032 ii ( Gt' "" ii Office Use Only /0I CJI 1Permit#p+7{ iAmount /� MATTACII CSE 1 ,...Y..•..T•• 'f ��•a. romp rd 5 cC Permit expires 180 days from -' OCT 14 2022 ! ,issue date 1 _ ._J a�� -a 3 - �( 1 i BUILDING DEPARTMENT 6 , .4 3 g— EXPRESS BUILDING PERMITAPP ICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: J-3 W 1 1 \ Lw YActki'ço* Y Y t r1 (. o7S ASSESSOR'S INFORMATION: f /� Map: WA( Parcel: (�(, ''OWNER: MI l '�`t- vt_y_j. 3 l W Ivor-- cr sT - IA��Y/ NAME PREwooriAA,t ADDRESS Y . # CONTRACTOR: NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ 0.1) Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workmanompensation Insurance: (check one) C3'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 rr Replacement windows:# ..C� Replacement doors: # Roofing: #of Squares iebQ SCE ( )Remove existing* (max.2 layers) Insulation I Old Kings Highway/Historic` Dist. ( )Replacing like for like Pool fencing 04MaPpraVtt-I *The debris will be disposed of at: I U I)Z'Z2 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: 0 i Owners Signature(or attachment) 40 I' D— 05> Date: 1.01 4 c Z� 4. Approved By: t /4, Date: , '—/ Building Official esign EMAIL ADD Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No "� The Commonwealth of Massachusetts F.. bF 1. Department of Industrial Accidents a Iiii• 1 Congress Street, Suite 100 " Boston, MA 02114-2017 .,�-z�.�''� 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): !\1(' 5 Address: �3 WAYQ Or- YW�,�� L , City/State/Zip: (4, i /j hone #: �v� LL( O 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. C New construction 2._• I am a sole proprietor or partnership and have no employees working for me in 8. n Remodeling a capacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. El Demolition y [No workers'comp. insurance required.]' _ 10 Building addition 4.❑I 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.L_1 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.Q 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 hereb c r 1 u er th ains andpenalttii s of perjury that the information provided above is true and correct. / Signature: %JO ' Date: ( (�{ I 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: • IIRr OK • RECEIVED Y L' TOWN OF YARMOUTH e '" ? 1146 ROUTE 28. SOUTH YARMOUTH, MA 02664-4451 SEP t 2 1; i Telephone(508)398-2231 Ext 1292-Fax(508)398-0836 S ULD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE YAflivlOU l r, OLD KING'S HIGHWAY APPLICATION FOR CERTIFICATE OF APPROPRIATENESS Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as amended: for proposed work as described below&on plans drawings, photographs. &other supplemental info accompanying this application PLEASE SUBMIT!!CO ies OF SPEC SHEET(S),ELEVATIONS PHOTOS,&SUPPLEMENTAL INFORMATION. Check All Cate ories That A I Indicate type of Buildin 1)Exterior Buildin Construction: New Buildin (� 9: Commercial Residential 9 I 1 Addition Iterations Reroof Garage .,Shed Solar Panels Other 2)Exterior Painting .[Siding Shutters 11 Doors [Trim . I�,i , � �-- Other: Vd(A 3)Signs/Billboards J I New Sin Change to Existing Sign 4)Miscellaneous Structures: Fence Wall L Flagpole I (Pool Please type-or print legibly: I "It�ther: (i� fiCJ�.', Address of or posed work: rf5 IA Oorvat�1 fir, 41 '0 . _ �\�_ Map/Lot# Owner(s) r�+r�(�'3"1 Pc . Phone ``1-� �jJ((��j All applications must be s taunted by owner or accompanied by letter from owner approving submittal ttal of application. Mailing address.13_�r`� �r(�j k ll l,�aaN l� !` { 't J 1 t._ 6 6 %gear built j9. - /,� . Email �i.k�`(} , �� 1 y 't �,I�fi} i . fication method ,�1,�,^� , `�` ._�__Phone Email Agent/contractor \ v Phone# Mailing Address Email. Description of Proposed Work: Preferred notification method:____LL Phone Email CD_-P-o 1a Wiin bOW S- - - (240 cock- Q,U &artt K.-- Poo'cs • — kX C� Shy l�2 S -� - �x'� Vv* o — Signe (Owne or agent) _ _ _ Date 2 42� Owner/contractor/agent is aware that a permit is required from the Building Department (Check other departments also) .- If application is approved.approval is subject to a 10-day appeal period required by the Act This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections For Committee use only: Approved • Approved with ZModifications7, Denied Revd Date _ J plev Reason for Denial 1:14.4.4re.u-,-• �; Amount Lib%e0 Cash/CK#: 2. / — t! Rcvd by Signed lt/: F -.__ .,�.a+�� 45 Days: (! . ' `[ , QLD KING'S HIGHF,.,?'/ Date Signed/0//l/Lc z Z j Y' 1 APPLICATION# �0l E