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Home My WebLink AboutBLD-23-000976 �", ,yg pm 8 't,c 1'�n ]Oftice Use Only 40 Permit# O . . H !Amount tl'v i %j,`t. ..r.00 c�Ems$ �' j Permit expires 180 days from 'issue date /� Jj 6 LD-23 —oOv"7 EXPRESS BUILDING PERMIT APPLICATI 1 ' E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department AUG 2 3 2022 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT By: (508) 398-2231 Ext. 1261 1 CONSTRUCTION ADDRESS: \°‘ Yaik f 14, I DoicA -1 ao--\---h\lanyvtA - 02V'bt-f ASSESSOR'S INFORMATION: I ,,�,p Map: Paarcel: -7 c /OWNER: �C& 'C3 Co c>A� A Pc,„‘fiv Rd . �. a�M M C-i- t- 36 l/ NAME / PRESENT ADDRESS TEL. # /CONTRACTOR: v 1 IL L i Z V N IE ' MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ L.--- Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: U 3 AA Workcr'3 Comp.Peticy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove 7 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: Location of Facility I declare under penalties of rjury that the statement herein contained are true and correct to est of my knowledge and belief. I understand that any false answer(s) will be just cause for denial revocation of my lic e for pros ution under M.G.L .268,Section I. Applicant's Signature:_ t Date: LAwners Signature(or a ment) Date: 1� Approved By: ..-------- Date: Building Offici des' ee) ' E ADD S: 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 ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 5..� www.mass.gov/dia IMP Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): c J&me f ( OO 6L9 Address: Paj e £ City/State/Zip: 3 /ct(mnL,*r. ciz 'hone #: 11-1_ L0 fir j�� 72, 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 8. ❑ Remodeling any capacity.[No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. 9. [1] Demolition y [No workers'comp. insurance required.] 10 ❑ Building addition 4.N I 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.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.11I I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp. insurance.: 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 verificatio . I do hereby certi nder the pains and penalti Doff perjuu y that the information provided above is true and correct. Signature: Date: Phone#: Official use snly. 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#: p er KJ') I htlUire— r "T1 Pe '' Ul °o n '(_ • Jvtul F 45 V2 CD o <. - � Greenville fD fD Installation and Operating Instructions ■ The 1Otul F 45 V2 Greenville heater is listed to burn solid wood only. Do not burn any other fuels. • Read this entire manual before you install and use this appliance. • Save these instructions for future reference and make them available to anyone using or servicing the fireplace insert. ■ This wood heater requires periodic inspection and repair for proper operation. See this manual for specific maintenance information. It is against federal regulations to operate this wood heater in a manner inconsistent with the operating instructions in this owner's manual. This heater meets the 2020 U.S. Environmental Protection Agency's emission limits for wood heaters manufactured after May 15,2020. Une version francaise de ce manuel est disponible au telechargement sur wwwjotul.ca JOTUE