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Home My WebLink AboutBLD-23-002317 _ - OffY`9R (a I� , „J b 12 f J zr/ :I Office Use Only --- , .. -7O ;Permit# c j,, t/Dd r; ! c O . ` i411- . .�H {Amount �d U (TO tA NATTA M eSE I "t*°o..,�°"'cod 1Permit expires 180 days from l issue date 5 Lp-a3-d d l3i ') EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R E C E I V '_ 1 1146 Route 28 1 South Yarmouth, MA 02664 I OCT 28 2022 (508) 398-2231 Ext. 1261 L. _ BUILDING DEPARTMENT CONSTRUCTION ADDRESS: ! b y 2oc 1 F CA oy —--- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: (7:9 NASA f b k/ izo,t.. a(ri- 47:7 Ma 7 % 9 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esential ❑Commercial Est.Cost of Construction$ d 5d d o., CI id (1 Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) ,01<t_Lal 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 /U1C. Replacement windows: # /(v Replacement doors: # 3 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation TOId Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ;jI J' .. ;p(:0 4,j'li/J/.s At /4- 3-/ 5)02- - • Location of Facility 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 revocati n of m license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: /d — Z — aZ_ :::::ture :::::::ial Date: f O '' OR - �'Z Date: �� ,./. (or design IAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 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 Department of Industrial Accidents _ 'I 1 Congress Street, Suite 100 ��= .c.1Boston, MA 02114-2017 MP5'•`' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual). 1- 4 /✓ /b,4--rC /� Address: X6 ,Y c q 1C' (A l City/State/Zip: �,�,,�Yh- i2i Phone #: 4/7 7 2 0 9- 0 Are you an employer?ICheck the appropriate box: Type of project (required): I.❑I am a employer with employees(full and/or part-time).* 7. L New construction 2.❑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. ❑ Demolition y [No workers'comp.insurance required.]` 4.❑ my I am a homeowner and will be hiring contractors to conduct all work on 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 5.1]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. 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 under th ' s and penalties of perjury that the information provided above is true and correct. Signature: Date: ye) 2 e --- 2 Z 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#: A . , TOWN OF YARMOUTH 41;0 7:— -27-- , 1, . t.:,- ;.:iLA :‘ o, , - .,#. 1146 ROUTE 28,SOUTH YARMOUTH, MA 02664-4451 N :.;* Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836 ,, „ia 'OLD NG'S HIGHWAY HISTORIC DISTRICT COMMITTEE /41MOUT, 1 OLD Ki(-40'S 1-401--yv,;,o' „,,,, APPLICATION FOR CERTIFICATE OF APPROPRIATENESS Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as amended,for proposed work as described below&on plans, drawings,photographs, &other supplemental info accompanying this application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S),ELEVATIONS PHOTOS,&SUPPLEMENTAL INFORMATION. Check All Categories That Apply: Indicate type of Building: Commercial III Residential 1) Exterior Buildin Construction: 'New Building 1-1 Addition Iterations El Rerooffl Garage, riShed Solar Panels El 10ther: 2) Exterior Painting: 71Siding Shutters 11 Doors Drim jjOther: ,i',•-- ' ', 4 i , , 3)Signs/Billboards: ri NewAgn Change to Existing Sign 4) Miscellaneous Structures: LiFence Wall EFiagpole 17 Pool EjOther Please type or print legibly: Address of proposed work: Map/Lot# 1113//011 Owner(s): 964 Route 6A Realty Trust(John Nash Trustee) Phone#: All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: 964 Route 6A Yarmouth Port MA 02675 Year built: 1994 Email: Preferred notification method: CI Phone Email Agent/contractor: John Nash Phone#: Mailing Address: 964 Route 6A Yarmouth Port MA 02675 Email:jgnash@comcast.net Preferred notification method: El Phone 0 Email Description of Proposed Work: 1. Replace roof with Moire Black Landmark shingles. 2. Replace OH windows with Harvey Classic DR windows (black exterior w/6 over 6 grilles), full screens and white asek trim. 3. Replace kitchen casement window with a Harvey gliding window (black exterior) with asek trim. 4. Replace slider and front entry door (match existing) w/storm door. 5. Replace back door with full view with storm door Signed(Owner or agent): Date: 04-28-22 ;0. Owner/contractor/agent is aware that a permit is required from the Building Department(Check other departments,also.) ;',.• If application is approved,approval is subject to a 10-day appeal period required by the Act.'i. This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. All new construction will be subject,inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. For Committee use only: V Approved Approved with Modifications Denied Rcvd Date: LicitAPe Reason for Denial.... Amount Rcvd Cash/CK# L C2:skl ' Signed: IV/ (elb ---- 1 by: ei.5 ' 011114 .45 Days: ) illtplill." 4,, -'-- A r, 1 /AI P I I I I PrAr Date Signed: i> 2 3 247 2 2---- lia Aar. f' APPLICATION#: .22e.'PC°61 , 1