HomeMy WebLinkAboutBLD-23-000055 �Y`-- COffice Use Only •
O �, Permit#CAI
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Tissue date
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EXPRESS BUILDING PERMIT APPLICAT IiRSE C E I V E D
TOWN OF YARMOUTH
Yarmouth Building Department JUL 012022
1146 Route 28
South Yarmouth, MA 02664 BUILDING DEPARTMENT
I )CONSTRUCTION ADDRESS: / ,�V<.Jbo A YT:
ASSESSOR'S INFORMATION•
gMap: Parcel:
/ OWNER: NAME �� 03 OS D—e6 1)6 V
V PRESENT ADDRESS
TEL. #
CONTRACTOR: SD 1_
36 NAME MAILING ADDRESS TEL. ��
#
❑Residential ❑Commercial Est.Cost of Construction$ ! V°
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Wor s Compensation Insurance: (check one)
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 ' la e Repment wino s:# Replacement doors: #
. O ('
,/ Roofing: #of Squares .c i )Remo7e existin * (ma
x.x.2 layers) Insulation
V Old Kings Highway/Historic Dist.
2p11JY ( )Replacing like for like Pool fencing
*The debris wiII be dis eWa:
Location of Facility
I declare under penalties of perjury that the state ents 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 license d for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature:
/ Date:
✓ Owners Signature(or attachment) 1 x ; 00 C9
Dater'?
Approved By: v
Building Off (o ignee Date:
EMAIL ADDRES .
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 D No
\ The Commonwealth of Massachusetts
Department oflndustrialAccidents
:. Il7M 1 Congress Street, Suite 100
Boston, MA 02114-2017
,,,:.= www.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / • ease Print Legibly
C.
Name (Business/Organizati 1..,. . 1 ual): )m
tio.
\ 1
c .
".
Address: r 6 F V civvb
City/State/Zip: \_ Phone #: 0c�S . v i3 tJ V
-7Are you an employer?Check th appropriate box:
Type of project(required):
1.—_ I am a employer with employees(full and/or part-time).* —
7. _ New construction
2.0 I m a sole proprietor or partnership and have no employees working for me in
ny capacity. [No workers'comp.insurance required.] 8. ❑ Remodeling
3. I am a homeowner doing all work myself. 9. ❑ Demolition
y [No workers'comp. insurance required.]t
4.0 I am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10 ❑ Building addition
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.
These sub-contractors have employees and have workers'comp. insurance.t 13•❑Roof repairs
6.11 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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 verificati. .
/I do hereby ce • nder ze pains and penalties of perjury that the information provided above is true'and correct.
Signature: 0.,_
✓ `, )
Date:
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#:
Sherman, Lisa
From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net>
Sent: Friday,June 10, 2022 2:29 PM
To: Sherman, Lisa
Subject: Re:22-E13077 21 Perch Pond Way
11 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.
The roof shown in the photo looks pretty good. Maybe it has problems elsewhere.
approve of the new shingles of choice.
Richard
On 06/10/2022 9:29 AM Sherman, Lisa<Isherman@yarmouth.ma.us>wrote:
if I
JUN I 0 ?Ii22
Hi Richard,
YARMOU FH
LD KING'S Hi °I I WAY
Resident would like to replace the roof at 21 Perch Pond Way. Weathered Wood,
which is the closest they can find to the current color, which was approved by
OKH a few years ago.
Please let me know if you need any additional information.
Thanks Richard,
Lisa
Lisa Sherman
Office Administrator
Old Kings Highway Committee/Yarmouth Historical Commission
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APPROVED;
I L_ NG'S HIG'
OLO 20n K1
2022 WZI
jit\I 1 .0 1 Poet )1 ()NIA
YARMOUTH
OLD KING'S HIGHWAY
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