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Home My WebLink AboutBLD-23-002653 C. u 111 0 61 i ) )1 c 1?rZ `Office Use Only •Y 'k. ► Permit#e,at.553 O H Amount tt4C5� t* M,, 71„ 4' +�.,,a„ ,.s 2I Permit expires 180 days from y; issue date EXPRESS BUILDING PERMIT APPLICATI I `- E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department NOV 14 2022 1146 Route 28 South Yarmouth, MA 02664 BUIL ( NT (508) 398-2231 Ext. 1261 By. CONSTRUCTION ADDRESS: / 7 LA.L.L J. ASSESSOR'S INFORMATION: / , ,Map: Parcel: OWNER: WetC/�tt -''v►e 1 i I C4 IC-e— I2 Nfri.ME PRESENT ADDRESS TEL. # CONTRACTOR: COP:(4- b S Z h I t 1-E---4" 1 -4- V l i 5% rn C SLAS LOD(.0 S NAME MAILING ADDRESS TEL.# ,+�,� o0 Residential 0 Commercial Est.Cost of Construction$ l0 / Home Improvement Contractor Lic.# \, Le S t,P Construction Supervisor Lic.# C S_U 6 I(')�"\ 0 Workman's Compensation Insurance: (check one) 0 I am the homeowner I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent D Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares />/:2- (❑)Remove existing*(max.2 layers) Insulation I J l l Old Kings Highway/Historic Dist. ,I►NI1 Replacing like for like Pool fencing El *The debris will be disposed of at: 1 ;71Ok Location of Facility I declare under penalties of perjury t 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 do ,f m,'cense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ,A��.____— Date: (//(/ eoe : Owners Signature(or attachment) CV-eV— )4 Date: j Approved By: ate: //' /7 `" Building Official(or desi e) EMAIL ADDRESS: Zoning District: Historical District: Li Yes I' No Flood Plain Zone: Li Yes I No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 1 No . Yes No The Commonwealth of Massachusetts 1....-4......— Department of Industrial Accidents t.;ctt = 1 Congress Street, Suite 100 _44 Boston, MA 02114-2017 „o Y• ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): Pak—rtii__J—Cti....01of Address: P,c'. 0 d)6 pig City/State/Zip: YCr t v 0,:;f(& vv1,01— baG 71- Phone #: —27Y—35 3— to£5 Are you an employer?Check the appropriate box: Type of project(required): 1. i am a employer with employees(full and/or part-time).* 7. ❑New construction 2 lama sole proprietor or partnership and have no employees working, for me in 8. Remodelin an ca aci g y p ty.[No workers'comp.insurance required.) 3. I am a homeowner doingall work myself. t 9. ❑Demolition ❑ y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on mY P roPenY� I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 l.QElectrical 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. 1" Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0We 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. tContractors 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 er tep ' s and penalties of perjury that the information provided above is true and correct. Signature: Date: // it/p6ZZ_ Phone#: 77Y— S' — 6 85�- 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#: Division of Occupational Licensure . Board of Building Re ulationst and Standards Cons ion .. y CS-081040 ti pires:04104i2024 PATRICK•H*COBS 28 WHITTIER/DRIVE DENNIS MA 1638 :i • °_ Commissioner d A'. lefemckua_, ----" THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reams E t' n = 155888 05/14/2024 ~, PATRICK JACOBS D/B/A P.JACOBS CUSTOM CARPENTRY AND REMODELING PATRICK;JACOBS 28 WMTrER DR. cx � 1 , DENNIS,MA 02638 , �o<wn -- ;,��, Undersecretary Town of Yarmouth Building Dept. Rt 28 South Yarmouth, Ma 02664 Re: 17 Lake Road West Yarmouth, MA 02673 We are having some work done, Roofing and Siding, on our property at 17 Lake Road in West Yarmouth. We have switched contractors and will now be using Pat Jacobs for the work in question. Should you have any questions, please contact us at 508-685- 3755 or 508-685-9487 Thank you.. Wayne Hunter Kelley Hunter 17 Lake Road West Yarmouth, MA 02673 508-685-3755-Kelley 508-685-9487-Wayne