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Home My WebLink AboutBLD-23-000083 E�Y.. e_t ` — , (� 1 Z� Office Use Only O AR' 4, d � �c,.t,'=� 0` Permit ext) I . $' Amount ,3S ,tb Permit expires 180 days from issue date 61. D - 3 -6d6.0g3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 JUL 0 6 2022 South Yarmouth, MA 02664 __ _ (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: CJ c JkJe, V C .r h S- Yap afrjjh—Al— A- ASSESSOR'S INFORMATION: Map: Parcel: OWNER:'' /4J4 ad Dcvi Ceti 0 L 4 f o r 663-- Ti W — ° el NAME PRESENT ADDRESS u TEL. # CONTRACTOR: gal he D t, / s/ cE.l ,,A 5 ylay tr C l(l k 6-64r--?31 355 NAME MAILING ADDRESS TEL.# Residential [(Commercial ,� Est.Cost of Construction$ /�t .1 / Home Improvement Contractor Lic.# 16,6 Construction Supervisor Lic.# Ja LI a Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor FAKhave Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation Iv l El Old Kings Highway/Historic Dist. Replacing like for like Pool fencing I I *The debris will be disposed of at: tV A 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 re ocation of my lie and for rosecution under M.G.L.Ch.268,Section I. r Applicant's Signature: �� I��Y'[G�, �)t Date: - 6'— . Owners Signature(or attachment) ;' , ir;' Date: Approved By: Date: ) 7 Buildin •'ici, or designee) EMAI 'u DRESS: Zoning District: Historical District: G Yes -1 No Flood Plain Zone: I' Yes D No Water Resource Protection District: Within 100 ft.of Wetlands: Li Yes 0 No D Yes r i No ��- The Commonwealth of Massachusetts Department of Industrial Accidents _'lilfi►=„ 1 Congress Street,Suite 100 _iti'; 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 Leeib1v Name (Business/Organization/Individual): A .1 C 4`e :' l e y/ Address: 16-5 V hci er?x 55 �r� City/State/Zip:fire,WE)et/ MA- 6 63 1 Phone#: S6 T- 31 r Are you au employer?Check the appropriate box: Type of project(required): 1.0(am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9 El Demolition 10 Q Building addition 4.1=II 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 5.01 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.* 14. her 5'n � la+ 1h 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§I(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. f 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: Aar M " (. Ckaritr Policy#or Self-ins.Lie.#: Ube V \ So . J t 06 Expiration Date: t -6 Job Site Address: SS ' 7 Vue I\CcL k\ fA City/State/Zip: y4ti 1 u41l Il!4 09.6106 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 certi under thep . and penalties of perjury that the information provided t above is true and correct. / Signature: Date: —(7(o_, Phone#: gat a 3 7 333 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#: Housing fi ,Asistane Corporation Cape Cod IMPORTANT NOTICE Weatherization contractors must pull a building permit from your town prior to installing any and all weatherization measures ordered by the Housing Assistance Corporation energy auditors. In order for a town to issue a permit, taxes must be current according to the town records. Your signature below indicates that your taxes are up to date. If not, HAC will put your weatherization work on hold until you notify HAC that your taxes are up to date. I acknowledge that my taxes are current. Owner's Signature Date 0 0 0 live learn work grow 460 West Main St. Hyannis, MA 02601 hac@haconcapecod.org 508-771-5400 fax: 508-775-7434' = HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing; attic& basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessaryto perform weatherization. 2. Time is of the essence>In con pl li oY "' erization work,therefore I agree that I will not delay Or,canjei weatherization services;especially if major repair work (ie roof, electrical work, etc). has contracted. I;understand that requests for contractor preference will be noted but not guaranteed 4. I agree to compliWitli lousing Assistance Corporation'to complete program mandated quality check inspection visits within 30 days of completion of each phase of work. 5. I understand that multiple visits by various inspectors may be required throughout the process. 6. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. , .. I have read the provisions o agreerne tea d give my consent. /9 Home Owner(signature _.- _ Date: Home Owner email: Agent:(signature) Date: Agency Approved Weatherization Company: All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save M.T. McMahon & Son Inc. Frontier Energy Solutions Lohr Home Improvement Cazeault Agency Signature: Date: For Natural Gas Customers: I have received the National Grid Discount Rate Application form from my auditor. Customer Initials v. 8.19 Commonwealth of Massachusetts 111-1 Division of Occupational Licensure Board of Building Reggulations and Standards C'I ConstructiqupIerr Specialty CSSL-103842pires:02/23/2024 SHAYNE DEWITT ) r N 161 COMMONS WAY ` ��, BREWSTER k1 026310t, ' . I or r. 1"��t.tv�ta�'�` Commissioner cttaf' tJl�ncJ+�a THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affair &Business Regulation HOME IMPROV ' -, CONTRACTOR TYP r • r&i dual 1�1OS6 r1 .a23 SHAYNE DEWITT D/BIA ALL CAPE ENERGY SHAYNE DEWITT 155 UNDERPASS RD l BREWSTER,MA 02381 Undersecretary Construction Supervisor Specialty Restricted to: CSSL-IC-Insulation Contractor Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.govfdp1 Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 ", (//1 141. t valid without signature •