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Home My WebLink AboutBLD-23-000324 C-6 I Z v/Z2.— Office Use Only `*' iN Permit# e., /y .. Amount...V.4 ~t TA 1,*c Permit expires 180 days from .::.• issue date &4 - 23 -ddO3J44 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146Route28 RECEIVE ® South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ir JUL 18 2022 CONSTRUCTION ADDRESS: 3 hç R i l m m n!N� ) f Ef'ARTMENT By _ ASSESSOR'S INFORMATION: —_._.________— Map: / Parcel: ,s ,r �7 OWNER: e-i7( kEWer /35 7—kcA>/ c /e 42/ 6M—.7 46' 6.39/ NAME PRESENT ADDR SS, 1 TEL. # CONTRACTOR: gal dr � � l �� / rli f402 -O F'24'( "9L NAME MAIADDRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ /6 C) Home Improvement Contractor Lic.# `16 re' Construction Supervisor Lic.# Workman's Compensation Insurance: heck one) 0 I am the homeowner I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: _L 're- 14VSt Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:#,1j r kyif ,J Replacement doors: # � /1d lL"44Ins`li Roofing: #of Squares (❑)Remove existing*(u(ax.�Cayet`s Insuta ion n nOld Kings Highway/Historic Dist. Replacing like for like Pool fencing I l ap pay gGe /7l/0flz *The debris will be disposed of at: /21C C / /"1 ! 0✓ /V U d4I Location of Facility I declare under penalties of per'ury that the statements herein ., tamed 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 .' ation of my i ense..r far.rosecution under M.G.L.Ch.268,Section 1. (� f Q` Applicant's Signature: —�' j ��j Date: / ! O —2d a- 00/%- qr Owners Signature(or attachment)' y / Date: �!! ��d Approved By: "'� Date: �/�2- Building Official(o, - EMAIL ADDR : 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 - Department of Industrial Accidents iatiritE I Congress Street, Suite 100 _`ti. E` Boston, MA 02114-2017 c — �Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly AName (Business/Organization/Individual): CP f�tz-1 \ 6[fe i 7ea�� L r/ Address: &,z--7zy(_s ForA City/State/Zip: gi,) ,,,vC 626- `hone#: 56Z'— /—i:5;' Are you an employer?Check the appropriate box: l Type of project(required): 1.❑I a employer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 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 11.QElectrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. oof repairs These sub-contractors have employees and have workers'comp.insurance.: f/ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other e 152,§1(4),and we have no employees.[No workers'comp.insurance required.) R6219 Q c *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: C1) U't_ /A)c Policy#or Self-ins.Lic.#: 5, 6// 5 ' Expiration Date: /- /— c:90 3 Job Site Address:/ 5-71ddec 4/e,& City/State/Zip:A �/ 122?6brr Attach a copy of the workers' compensation policy declaration page(showing the policy number and a pirat on 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ccfif u�rjder the pal an aides of perjury that the information provided above is true and correct Signature: (4---)-- Date: 2> /3 20 2 Phone#: Q r , 9 - ''9' ; v Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: es 1' all 1:15 / West Yarmouth - Captain's Hill May 8 9:13 PM at c Officj of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRATR TYPE:Individual Regis_ t`ation Ex i At' an 186088 09/27/2022 BARRY HALL D/B/A CREATIVE CARPENTRY BARRY HALL 3 BETTY'S PATH u W.YARM OUTH,MA 02673 r Undersecretary r Commonwealth of Massac : Division of Occu census Board of Building Re Pational Licensure usations and Standards ti� )RYR � z # �piPt?$ 12i31f2023 TY'S PATH t - YARMs gt r1! r_� L J ' - 't fp"--0 e,......,. , 1 a .... .. „ e U (7 Lisa From: R|[HARDGE6ENVVARTH ^rgegenwarth@cnmcasLnet> Sent! Monday,July 18,202Z4:3SpM To: Sherman, Lisa ��- Subject: Re: FVV:22-EBO82135ThacherShore ` ----- --'__-_� BUILDING DEPARTMENT _ay:�� ---------_ 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, N Otherwise delete this email. � � No problem with this like for like. | approve. (A- Richard ��. OnU7/18/3OJJ2:OOPK8 Sherman, Lisa<|sher,nmn@oyarmouth.nna.us>wrote: ^$r, � � ~ lie W; F* P, A ' '"I YARmo From:Sherman, Lisa<L6hernman@yannouth.na.us> Sent: Monday,July 1O, 2022 1:24PK0 To:Richard Gegenm/arth«r.8eQenwarth@cnrncast.net» Cc:Sherman, Lisa<LSherman@yorrnouth.ma.us> Subject:22'G8082 135ThocherShore Hi Richard, Resident would like to replace skylights. Like for like, same units that are there now, 'USt installing new ones. Please let me know if you need any additional information. Thanks Richard, [i6@ Lisa Sherman Office Administrator Old Kings Highway Committee/Yarmouth Historical Commission Town of Yarmouth 508-398-2231,ext. 1292 isherman@Yarmouth,ma.us 2 1 3 c :rti—V---E—in i ;' ., 4,3s.', iE,..a+7:'Ip 'fir ° .,i5 �' •„., ,`° ,�) ° . 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