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HomeMy WebLinkAboutBLD-23-000772 .01...Y44 Office Use Only , T R E \ ,,Pennit#1,� C, JZ 00.arig1 Amount �O y` t 1Ms 4. /i '' AUG 15 2022 - Y Permit expires 180 days from .: �� ___ issue date BUILDING DEPARTMENT a //�'�r-y�--�� By: �� "Vt�CJ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ! &,tle -t ne_ I,JeS-1 - 0.4. ASSESSOR'S INFORMATION: Map: Parcel: Q OWNER: V.„64.1e. 6-Valnc 4. Cima+',-,v-Eva.S SI'i1' ( r 2 - 3- 62 - ` 74'7 NAME ppPRESENT ADDRESS TEL. # d CONTRACTOR: airi dc._ja coos r,O. 60x 3`4`( Y-lPocr 77(- 3 S."3-c, s-a NAME MAILING ADDRESS TEL.# ,�,1 Ksidential 0 Commercial Est.Cost of Construction$ 12,d Do ,U V Home Improvement Contractor Lic.# S. Gt _,'f`f i. Construction Supervisor Lic.# C� �Zr a Workman's Compensation Insuranc ( eck one)` S&� �' OA U 0 I am the homeowner am the sole proprietor El I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Ej Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# 8 Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation L __ Old Kings Highway/Historic Dist. 0)Replacing like for like J Pool fencing n *The debris will be disposed of at: (7�l\•(,� Location of Facility I declare under penalties of perjury f.t th• stat r• nts 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 re .:tio/ o icense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Q ,- Date: a/7.Va-0ao� Owners Signature(or attachment) ate• Approved By: r Date: '� �� �� Building Official(o desi e) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes } No Flood Plain Zone: ❑ Yes No Water Resource Protection District: Within 100 ft.of Wetlands: IT Yes 'Ll No Yes No The Commonwealth of Massachusetts = Department of IndrustrialAcciderzts g '=° l= 1 Congress Street, Suite 100 yf Boston,MA 02114-2017 to* www.mass.Gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/1ndividual): Qa` SaW(os Address: P 0 . B 0)c '74'K City/State/Zip:YQrottst1 •A,-f / bi- o a„ ,75— Phone#: 77V 3S7 -6 e Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with employees(full and/or part-time).* 7. Q New construction 2.1! I am a sole proprietor or partnership and have no employees working for me in 1 capacity.[No workers'comp.insurance required.] 8. modeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Q Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E] Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 1 i•Q Electr(eaI repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box in 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. .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 certi t r tl pa' nd penalties of petjuly that the information provided above is true and correct Signature: Date: a.7/d-Da-at Phone#: 7 4/-.? —6 gf"-- 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#: Division of Occupational Licensure Board of Building,,,,R,,e�ulations and Standards Consti; icon isor CS-081040 t` spires:04/04/2024 ' PATRICK H JAACOBS 28 WHITTIER/DRIVE , DENNIS MA 0J638 Commissioner da da 1 . t c..wo a THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 165888 05/14/2024 PATRICK JACOBS D/B/A P.JACOBS CUSTOM CARPENTRY AND REMODELING PATRICK JACOBS 28 WHITTER DR. r Z/ti ,✓f -,z/w0! 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' R t , ���,, � U TOWN N OF YA R M O U TH r 1146 ROUTE 2u SO T H YAftf�1C7UTH,MA c�2661-4451 7 :j UU;,_ 5 20z Telephone(508)398-2231 Ext, 1292-Fax(508)398-0835 vAR LP KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE I, OW KING'S Hs'(af-Il''4';r!'v I APPLICATION FOR CERTIFICATE OF APPROPRIATENESS Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Ads 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 Appl : Indicate type of Building; Commercial IX..�.', Residential 1)Exterior Buildin Construction: INew Building .t 'Addition j1,Iterations IReroof Garage fJShed I 'Solar Panels I 'Other: RECEIVED 2)Exterior Painting: Siding Shutters 11.Doors rim Other: 3)Signs/Billboards: [1 New Si n Change to Ex'sting Sign AUG 1 0 2022 j 4)Miscellaneous Structures: Fence Wall I'Flagpole (Pool 'Other; Please type or print legibly: BUILDING DEPgRT 1 Address of proposed work: I �l(e. pc Wes f Qc M x._ a MENT t aptLot# -- Owner(s): V-e 6.rail.S4 Phone# 4/7 All applications must be submitted by owner or accompanied by letter from owner approving submittal it�of appli at on. Mailing address; 9 6G(i -�{ Vies-{-_ cat. , 5 _ Year built; Email Preferred notification method. PhoneEj.._.. .Email Agent/contractor &. - tc, Y c 4o8sZ Phone rt. 77 _3 Mailing Address: P 0• BOX 31-H YLt r e.4.0t1 P0,r± 4, t eg- oa-e,7f Email: 4t©tOs 78® c�Q(,too. cowl, < Preferred notification method Li — �� �< < Phone Emailbescripti©n�f�F'r©posed Work: rsw. Signed(Owner or agent) >71 +P tCUl t OLD k.iN_ S , Date 6/13,/e1CA -ta C?wnericontractorlagent is aware that permit is required from the Building I-epartment.(Check other departments also) It application is approved approval is object to a t0-dayappeal period regr,ired by the Act This certificate is good for one year from approval date or upon date of expm,alion of Building Permit,whichever date shalt be later. All new construction will be subject to inspection by OKH OKH-approved pla rs MUST be avail p able on-stile for framing&final ins Ec1i6Yrs, For Committee use only: Approved , - --- Approved with V fviadifications Rcvd Date: I2. Denied Amount 10.1.0 �.. 4 tc" G,.. 2 � .+c,y .. CdsWCK#: r5L �� Rcvd by L-4. Signed: _ 45 Days: _ - r �. r . Date Signed 2 Z 1 1 APPLICATION#. c!©-