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Home My WebLink AboutBLD-23-000082 o ;y 1. /.�f"`^-'' - �� ! " C� ✓ith? Office Use Only .T f =., 'ti►0- -7 17 'C.` 5,2-O --6, 9 i -- [!�OD Permit#CL t- 3— ainnin s Amount 35,O Permit expires 180 days from ' issue date &D 23-1odez EXPRESS BUILDING PERMIT APPLICA V. TOWN OF YARMOUTH ,__� 1 �/ E D Yarmouth Building Department 1146 Route 28 JUL 0 6 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 By___ __G DEPARTMENT UILDIN�; A CONSTRUCTION ADDRESS: lie— 5 ;� V ' \c r hi- S. Qll Mid LIF ASSESSOR'S INFORMATION: �� , nMap: Parcel: �7'7 f �i OWNER:M_�� c W J o V1 I n , cJ f� J 1 1� C tu NAME PRESENT ADDRESS TEL. # CONTRACTOR: 5'Y,�y he D lam' r . /('1 Chi rY15 w( ,y tt /,I� 6 431 355 3' NAME MAILING ADDRESS TEL.# Oesidential El Commercial Est.Cost of Construction$ 1417S'66 Home Improvement Contractor Lic.# 16 6reCr Construction Supervisor Lic.# /6 5r q a Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor 8 I have Worker's Compensation Insurance Insurance Company Name: _ Worker's Comp.Policy# WORK TO BE PERFORMED Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove 0 Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation J i Old Kings Highway/Historic Dist. Replacing like for like Pool fencing n *The debris will be disposed of at: 4//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 ocatiioon of my lic and for rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: k /� �G 1 G,Ci % Date: -7-0 4_ l Owners Signature(or attachment) 5 -L° (X 'i Date: Approved By: L -7� V r - Date: J /�" �.—_ Building Official esi EMAIL ADDRESS: - Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts _JIJ r Department oflndustrialAccidents sallvo 1 Congress Street, Suite 100 s Boston, MA 02114-2017 .,5°•` wwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le 'bl Name (Business/Organization/Individual): 1 Address: i 5 (2 ' 1 e ^ ' . 1 f i1 City/State/Zip:,. die w /13i( !l''1j 4 c. ,(' I Phone#: -� .--L-0 I '3 3 Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with employees(full and/or part-time).* 7. 0 New construction 2.1:II am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling 3•01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees. 11.QEleCtrical repairs or additions 5.12I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.Q Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: U.El Roof repairs 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14• they T° l 6() -1-4 152,§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. 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: F-7,...,,i_, , L%A, -h., Policy#or Self-ins.Lie.#: LA C� VO1 f JT ,,,,,,, — < �' Expiration Date: f✓i ., - ,�- ,/ Job Site Address: -` - `.) , Flue f\vG g, City/State/Zip: Y r o jd A , 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 the p "ns and penalties of perjury that the information provided above is true and correct. Signature: Date: — Phone#: 60 r-- 3 7 — 3353 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 Pet-son: Phone#: ' per. r Housing f4 � Assistance 0,Y 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. - 2 .. , ( 4._ 7-.....____„, Owner's Signature Date 1 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 necessary to perform weatherization. 2. Time is of the essence in completion of weatherization work, therefore I agree that I will not delay dr,cancel weatherization services; especially if major repair work (le roof, electrical work, etc). has contracted. 3. I understand that requests for contractor preference will be noted but not guaranteed. 4. I agree to comply with Housing 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 agreeme/ t a d give my consent. 6 Home Owner signature r� _, 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 Division of Occupational Licensure Board of Building Requlations and Standards t'IIis Constructig upe F Specialty CSSL-103842 z' tcpires:02/23/2024 SHAYNE DEWITT 161 COMMONS WAY jQ BREWSTER IG1_A 02631 i 1914'st. 3:* Commissioner da8G Z,&iLLut, THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 166888 12/28/2023 SHAYNE DEWITT D/B/A ALL CAPE ENERGY SHAYNE DEWITT 155 UNDERPASS RD BREWSTER,MA 023610�`' _"(_ 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.gov/dp1 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 ZAZier' '/ ' t valid without signature