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Home My WebLink AboutBLD-22-007285 -i Y"ia / Office Use Only OR p`� t: � ryk t � 2�� 9 i /) )3� Permit# e a/J4 ,— • lO _ . Ht R�ijbiii � � 'Amount 5-0, Da ''� MATTACM CSE : *°"°'"4'�°"55 c'`�/ ]Permit expires 180 days from c- :-.. ;issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yaunouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 2 g Aft 2I G t �� a,,/' ►,� �n � ,1� 7 ASSESSOR'S INFORMATION: Map: Parcel: (� OWNER: tOp"fE 6 01/4 /18)Le, 76(` -23e" 13 � PRESENT ADDRESS TEL. # CONTRACTOR: 114;e1( / NAME MAILING ADDRESS TEL.# U� ) / Residential ❑Commercial Est.Cost of Construction$ p[-cg 0. Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workm 's Compensation Insurance: (check one) g 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: # / v Roofing: #of Squares I Li ( )Remove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: / / LZ/S. 'f (J Location of Facility I declare under penalties of perjury that t e 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 revoc.:a .f my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: V Owners Signature(or attachment) y Date: 6` 14 ,z 0 2 t'/ Approved By: Date: •�7j Building Official de ee) EMAIL ADD Zoning District: Historical District: ❑ Yes E No Flood Plain Zone: E Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No G Yes E No The Commonwealth of Massachusetts 1_'_ _ IDepartment of Industrial Accidents 41� ��_ I Congress Street, Suite 100 _ `_ Boston, MA 02114-2017 ii.12:\ WO 5',s'` 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): 1)I)v I,Gt$ y u ii e r ' I Address: 2 A ('oYJI,A „t, . �/y� o i e ?2C 730- i 2 4y� City/State/Zip: aLcim,,L I,) pier ) ► l l A Phone #: Are you an employer?C ck the appropriate box: Type of project(required): 1.❑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. C Demolition 3.VI am a homeowner doing all work myself[No workers'comp.insurance required.] 10 El Building addition 4.0I 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 1 L Q Electrical repairs or additions proprietors with no employees. . - 12.n Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractprs have employees and have workers'comp.insurance.; 6.C We are a corporation and its officers have exercised their right of exemption per MGL c. 14.D 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 an the pains and penalties of perjury that the information provided above is true'and correct. l OD Slanature: Date: ( ` / �r li Phone#: 7 a l- - 38y ( .2, 9. , 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#: Sherman, Lisa From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net> Sent: Friday,June 17,2022 12:35 PM To: Sherman, Lisa Subject: Re: 22-E8078 28 Arrowhead Drive Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Seems like a simple "like for like". I approve. Richard On 06/17/2022 11:50 AM Sherman, Lisa<Isherman@yarmouth.ma.us>wrote p Chf 11:1 Hi Richard, Y Resident would like to replace the roof at 28 Arrowhead Drive; like for like, replace black with black. Please let me know if you need any additional information. Thanks Richard, Lisa Lisa Sherman Office Administrator Old Kings Highway Committee/Yarmouth Historical Commission Town of Yarmouth 508-398-2231,ext. 1292 ;42 I-11)6n 1Office Use Only „_ 4,.. 177—;;-• ' `V: t It 1Pennit# 4-;40114, '. ' , . 1 lAmount ...5-42, 06 0 . -ri-10, „„,.. ki 't.tA $.tz-% s 4' ,IJN I i ,,,t.6. 4 .... ;Permit expires 180 days from issue date '',Af IMOD t I 1 t , OLD KING'S Ril(qpIyAL v j F 0.--- e iv- - -Ti tXPRESS BUILDING PERMIT APPLICATION I TOWN OF YARMOUTH i 'iil' 1 .` 1 Yarmouth Building Department I Y AHIVIDD h I 1146 Route 28 OLD South Yarmouth,MA 02664 KING'S 1:11OFftvAIL j (508)398-2231 Ext. 1261 vc CONSTRUCTION ADDRESS: 2 E, Artohlteet,ii a/7., elteit201,91-7&,,,d); "0 6724 75 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: bOillj /3 PRESENT ADDRESS TEL, # CONTRACTOR: nil ti‘elf NAME MAILING ADDRESS TEL# hesidential 0 Commercial Est.Cost of Construction$ )2 6'V 0 Home Improvement Contractor Lie.# Construction Supervisor Lie.# Workmva's Compensation Insurance: (check one) 1:t I am the homeowner 0 I am the sole proprietor 0 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 I Li ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that t; 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 revoc; '• tf"mLlicense and for prosecution under M.G.L.Ch.263,Section I ‘..,'''-' Applicant's Signature: it 4- ......-- (..,-/ ---,.. Date: VI Owners Signature(or attachment) c >4),,. I Date: 6, i 4,zo Approved By; Date: Building Official(or designee) EMAIL ADDRESS. 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 El No G Yes D. No 115 Cr/8"