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Home My WebLink AboutBLD-23-001945 '� �f ,, ` C' tiG ;Permit# — „: 4 ,LI II J/u2 2 Amount-�� !Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICAT ON TOWN OF YARMOUTH RECEIVED Yarmouth Building Department �r 1146 Route 28 _ OCT 12 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By- _ r _ CONSTRUCTION ADDRESS: LS ei.C'6t 5.4 p- /e2G,rt a 7/(-�( G, -- y 7 ASSESSOR'S INFORMATION: — Map: Parcel: OWNER: �'J/s-! 44- /2'7-.r�1" . -- 1 NAME 4` ��4' �� s £ - 9e)c [/ i; . c" i�' CC cg`z, PRESENT ADDRESS irl.. # Email Address: r; CONTRACTOR _ c'-fry,--,t.:_ NAME MAILING ADDRESS ---- ,P # Email Address: Residential Commercial Est.Cost of Construction$ ?GOV.. Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workran' Compensation Insurance: (check one) et, tam 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 s Old Kings,Highway/Historic Dist. ( ')Re lacing like for like Co 6,trzeti-Liodteii '") ,5-ct tivt-z. *The debris will be disposed of at ,'%i'<?t... Y Location of Facility Cc/10r u 5 I declare under penalties of statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answe(s)��{Y perjury that the will be just cause for denial or rev ation of my license-and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: _; / �! /Z 2___vim-= / Owners Si Date: rf� Signature(or attachment) �' it ---_ 17.-2_e-.V‘--,..e. Date: /.'' /x�� f ?-- Approved By: y --Z Building Official i Date: /`�`�i Zoning District Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No l!CC l.un znonweairn of triassacnUsetis wiii11% z Department of Industrial Accidents 1 Cong ��f ress Street,Suite 100 . - N.,; Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le •bI Name (Business/Organization/Individual): (%G CI• 4ddress: 2:7 -`• / ` «I e� c)-Zz 7 .5� ,'ity/State/Zip: ,It'"7-5 C:,2 4 7 y ..3‘ 4 Phone #: � re you an employer? Check the appropriate box: I am a employer with Type of project (required): em ployees(full and/or part-time).* New I am a sole proprietor or partnership and have no employees working for me in 7. ❑Rem construction any capacity, [No workers'comp. insurance required.] 8. 0Remodeling N I am a homeowner doing all work myself. [No workers'comp. insurance required.]t �- 9. ❑ Demolition nI am a homeowner and will be hiring contractors to conduct all work on my property. I will 1.0 ❑ Bui1dIIlQ ensure that all contractors either have workers'co 5 addition mpensation insurance or are sae I l.❑ Electrical repairs or l proprietors with no employees, additions 12.El Plumbing repairs or additions I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp. insurance.t We are a corporation and its officers have exercised their right of exemption per MGL c. 52 §1(4),and we have no employees. 14.L,= Other /, �� ,,__, i [No workers'comp. insurance required.] y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informatiorL imeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating tractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have loyees. Lf the sub-contractors have employees, p o such they must provide their workers'camp,policy number. n an employer that is providing workers'compensation insurance or 'rmatian• J my employees. Below is the policy and job site Trance Company Name: cy# or Self-ins_ Lic. #: Expiration Date: Site Address: L7 �� : /�f 5 S - ach a copy of the worke��com �� • C#'ity/Stag/L,ip: sensation policy declaration page(showing the policy number and expiration date), use to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 'or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insu 0. a ..rage verificatio _ ranec e n hereby certify under the pains and penalties of perjury that the information provided above is true and correct. (' iature: ii �, Date: / i/ Z _ne#: . . -.. "'' )j)icial use only. Do not write in this area, to be completed by city or town official. :try or Town: (circlePermit/License# 3suin g Authority one): . Board of Health 2. BuiIdin De a Other g p rtment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 'ontact Person: Phone#: • OLD KING'S HIGHWAY HISTORIC DISTRICT EXPRESS PERMIT"Like for Like" Criteria The following criteria should be applied when making the determination to sign off on an Express Building Permit Application for a "Like for Like"OKH project. (Building Dept has the authority to approve ROOF and SIDING if they are comfortable that it is a true"Like/Like".) When in doubt,contact OKH Chairman. ROOFING • OKH to sign Express Building Permit if replacing like for like material if o asphalt shingles o cedar shingles o style is architectural or 3-tab(ok if switching from one to the other) o color is same or a visibly similar shade(i.e. Cobblestone Gray to Colonial Slate) o common shades are from light to dark: Cobblestone Gray, Colonial Slate, Georgetown Gray,Weathered Wood, Pewterwood,and Charcoal Black. • Certificate of Exemption if o proposed color change is visibly different(i.e. Light gray to black) o changing to a color not listed above o proposing rubber roofing • Certificate of Appropriateness if: o proposing metal roofing SIDING • OK to sign Express Building Permit if replacing like for like material and style o cedar shingles o wood clapboard o cement board(HardiPlank) • Certificate of Exemption if: o Proposing to change material(i.e.from wood to cement board) • Certificate of Appropriateness if: o changing style(i.e.cedar shingles to clapboard) o proposing synthetic/vinyl siding WINDOWS/DOORS • OK to sign Express Building Permit if: o exactly the same style, size and grille pattern as existing (or if adding grilles where there are none) o okay to trade out wood trim for Azek • Certificate of Exemption if following changes are not visible from a public way: o changing style (i.e. casement window to double hung window; full panel door to a door with glass) o changing size o adding or changing location • Certificate of Appropriateness if above changes are visible from a public way Sources for verifying existing colors/style/grilles: o Ask Applicant to see pictures(usually has pics on phone) o Refer to Assessor's Property Card photo o Google Earth o LaserFiche