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Home My WebLink AboutBLD-23-000468f a.YRR e6tJJA ;Office Use Only • $w. ;� I;...! C 7/ / iPermit# /� O(� 4 . H Amount �0,t G MATTA M CSEJ- °`°°"°`°.9 Permit expires 180 days from l issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R E C E I V E 1146 Route 28 South Yarmouth, MA 02664 JUL 2 9 2022 (508) 398-2231 Ext. 1261 _ .....] 1 5"-- BUI .DING DEPARTMENT CONSTRUCTION ADDRESS: ) 4 t IW i 24y 41014 ASSESSOR'S INFORMATION: / Map: ` Parcel: OWNER: )1LtLbb 1�0U4tiI/� b34iirIg. NAME PRESENT ADDRESS TEL. # CONTRACTOR: ! ` 46 lle) '-Qg � 01 noo V NAME MAILING ADDRESS TEL.# ia'Residential ❑Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm s Compensation Insurance: (check one) V I am 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 Replacement windows: # Replacement doors: # /Roofing: #of Squares ( )Remove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: L„✓ I (1 I 0(42 5 t!s/z Lo cation of Facili ty ty 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. y�pplicant's Signature: Date: V/Owners Signature(or attachment) ; Date: '7/0a 8 i a . Approved By: Date: Building Official(o sig EMAIL ADDRE 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 0 No \ The Commonwealth of Massachusetts =, = I Department of Industrial Accidents r,_ 1 Congress Street, Suite 100 '�lv`= •- Boston, MA 02114-2017 ��5�•`'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 ame (Business/Organization/Individual): Zel i vr912 C 4-(2/.r6, r Address: 2 /t;1e 1' eq. L/g., City/State/Zip: N.6 7 Phone #: -g1 � — i qt ' QaR -- 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 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp.insurance required.] 8. Remodeling 3.❑I am a homeowner doing all work myself. 9. Demolition v y [No workers'comp. insurance required.] 4.jI am a homeowner and will be hiring contractors to conduct all work on my property.e I will 10 Building addition . ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 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.❑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 verification. /Signature: I do hereby cify under thvains and penalties of perjury that the information provided above is true and correct. A e1/4n - iJ Date: Ie c2 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: RECEIVED 2 0 422j 72, 1‹,e) 69:kt Ce4A1-- BUILDING DEPARTMENT tsy: 77,4yeel1l ;)65 /4w/flax /, 4dt/ ALat /Wie, )7f 4e1,- ,7/ V511 RECEIVED LUL2 9 2022 BUILDING DEPARTMENT [3Y: [Space above this line reserved for Registry of Deeds use] QUITCLAIM DEED We, RALPH B. BARTLEY and SUSAN A. BARTLEY, being married to each other, both of West Yarmouth,MA for consideration paid and full consideration of FIVE HUNDRED EIGHTY THOUSAND AND 00/100 ($580,000.00) DOLLARS grant to WILLIAM COUGHLIN and ELISE ANN COUGHLIN, husband and wife as tenants by the entirety, of 29 Slayton Road,Melrose, MA 02176 with QUITCLAIM covenants the land with the buildings thereon, situated in Yarmouth (West), Barnstable County, Massachusetts, described as follows: LOT 50 In LAND COURT PLAN 28197B N The premises are conveyed subject to and with the benefit of all easements, restrictions, rights -10 of way, takings, reservations, exceptions and covenants of record, to the extent now in force and applicable, but not intending hereby to recreate or extend restrictions, reservations, exceptions and covenants previously terminated or expired. LL The Grantors hereby voluntarily release any and all rights of Homestead in the above- described property and further state under the pains and penalties of perjury that no former spouses, partners, or former partners in civil unions, or any other persons, person or entity that have the benefit of a Homestead by court order or otherwise in the above-described property. Meaning and intending to convey and hereby conveying the property conveyed to the Grantor by deed dated March 24, 2003 and registered with the Barnstable County Registry District of the Land Court as Document No. 912947 on Certificate of Title No. 168653. Executed as a seal instrument on the date annexed to my signature. Date:1� ' RALPH B. BARTLEY COMMONWEALTH OF MASSACHUSETTS County of Barnstable r On this 1�—4- day of July, 2022, before me, the undersigned notary public, personally appeared RALPH B. BARTLEY, ❑ personally known to me, or proved to me through satisfactory evidence of identification,which was Ef driver's license ❑ (other:) to be the person whose name is signed on the preceding or attached document, and who swore or affirmed to me that the contents of the documents are truthful and accurate to the best of his knowledge and belief, and acknowledged the foregoing to be his free act and deed and signed it voluntarily for its stated purpose. ,,/6( MARGARET M.MARSTONt Notary Public,Commonwealth of MassachusettsNotary Public My Commission Expires January 16,2026 My Commission Expires: Executed as a seal instrument on the date annexed to my signature. Date: 7q/ V-N USAN A. BARTLE COMMONWEALTH Of MASSACHUSETTS County of Barnstable On this 194 day of July, 2022, before me, the undersigned notary public, personally appeared SUSAN A. BARTLEY, ❑ personally known to me, or proved to me through satisfactory evidence of identification,which was 13 driver's license ❑ (other:) to be the person whose name is signed on the preceding or attached document, and who swore or affirmed to me that the contents of the documents are truthful and accurate to the best of her knowledge and belief, and acknowledged the foregoing to be her free act and deed and signed it voluntarily for its stated purpose. : —1---- * MARGARET M.MARSTON Notary Public I Notary Public,Commonwealth of Massachusetts My Commission Expires January 16,2026 My Commission Expires: