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EXPRESS BUILDING PERMIT APPLICATIO E. C. .1Y !D
TOWN OF YARMOUTH
Yarmouth Building Department JUL 07 2022
1146 Route 28
South Yarmouth, MA 02664 B Ur E N T
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 6 Dauphine Dr, Yarmouthport, MA 02675
ASSESSOR'S INFORMATION:
Map: 133 Parcel:33.1
OWNER: Tiffany and Nick Callahan, same as above 508-641-6605
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Jarnie Piria Jr. h —598-61-5-74-40
NAME MAILING ADDRESS TEL.#
0 Residential 0 Commercial Est.Cost of Construction$8800
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
B I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Arbella Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent D Duration (Fire Retardant Certificate attached?) Wood Stove D
Siding: #of Squares Replacement windows:#7 Replacement doors: #
Roofing: #of Squares (I )Remove existing*(max.2 layers) Insulation El
WIOld Kings Highway/Historic Dist. Replacing like for like Pool fencing El
*The debris will be'' disposed of at: Yarmouth Transfer Station
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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: .v.� Date: 1 17/c7;
Owners Signature( att ment) Date:
Approved By: 14:0 i- Date: 7
Building Official(or d ee) EMAIL ADDRESS:
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No Yes No
... !
, . .„ . . .
--,
IRECFNIED
TOWN OF YARMOUTH , I MAR 0 1 2022
i
_ ...j
1146 ROUTE 28. SOUTH YARMOUTH.MA 02664-4451 ... BUILTDING DEPARTMENT
Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
E B (OLO?Klki,G'S HIGHWAY HISTORIC DISTRICT COMMITTEE
YHhoik.r+k) c 1 APPLICATION FOR
OLD KING'S HiGHIAry
CERTIFICATE OF APPROPRIATENESS
Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as i
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 Residential
1)Exterior BuildirrIgiConstruction: New Building El Addition Iterations I Reroof FIGarage
ElShed I 'Solar Panels Other:
2)Exterior Painting: riSiding Shutters ri Doors EiTrim LlOther:
1 FE 8 3)Signs/Billboards: ri New a n Change topgoting Sign B 2 202?
rp
4)Miscellaneous Structures: 1 Fence Wall . Flagpole El Pool ['II Other: 1
Please type or print legibly:
Address of proposed work: Lc> Do.u.v\--woe. Ch--. Map/Lot# 1 )3/ -33, k
Owner(s).-TtcV0-1-S A- kNi C-Ic-ic::Aa'71 Cn..1.10hCBM Phone#: 5C:e-to4 I - 1ot005
All applications nlust be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: Us Dauqnvv-le "'Oc-. Year built: VT?y
Email: .i.gart.pm..11V(-- 4--} ff:6,ff\ 11,Ccry‘ Preferred notification method: El Phone 2 Email
Agent/contractor: -30,,vn ve V vc-v), Phone#: 508- K15-1P-1-1D
Mailing Address:.5.--‘ev\-el 1 I:1 c,r)A V Mc\Ile k`-'.,\C)C.4 OUP ---VC‘OCIThkrrk ON-. i *14-1- r.\V::';VI 0 alin 1
Email \ :(-1 CI_\lc- A.)rhck\-,naa. COOrx Preferred notification method: Ei Phone_ED Email
Description of ProPbsed Work:
to V)e.../J3 u...)‘r.6,0..A._15 — l casecci2A--A k.);1"‘Ifil...0 k:c`a )(--1‘.\--6-xarm -k. 5 -"\-0/1r-A-\ L-t--)0\601- 3
COJICAR V-10,7c13 kr. Vs-m-1 CZCXX-N. -4, \ t>e..AV-00CY-s,
it,:\\\ ts.),...).,r‘60,s. ox-e, wN-sk-vi c)\--).5\r,„pa, 5\sys,R, cor-o2_
Signed(Owner or agent): . Date' c:.!;%/,5/(:.?
Ownericontractortagent 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.
-, 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 to inspection by OKH,OKH-approved plans MUST be ailable on-site for framing&final inspections.
_ .
For Committee use only: /Approved • Approved with Modifications Denied
Rcvd Date, 21.3 ).2. Reason for Denial, ia.L.
Amount
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CashtCK#. 1403
Signed: gAlt., .44'-e6:„.4.
/ .
45 Days: , /--- k/--
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::', ,Ariell/MM Date Signed' 2.. 7-tt/ 2—°l 2-- ,.
1
APPLICATION# g)-1\:)0
—
YARKHOUTH OLD KJNG'S HIGHWAY HISTORIC DISTRICT COMMITTEE
APPLICANT'S RESPONSIBILITIES & APPLICATION CHECKLIST
APPLICANT'S RESPONSIBILITIES,
I All applications shall be filed on Commission-approved forms available at Town Hall and on the Town of
Yarmouth websks(wvmwvannouik.ma.us), An incomplete application can be the basis for or denial
o/ aNing, If you have any questions concerning your application, p|eeuo check with the Office Administrator
for clarification. .
2, Number mfcopies:
Certificate of Appropriateness Application(Front page)__1copy
General end/or sign spec sheet __4copies
Abutters'List(Map&Lot numbers only) __1copy
Elevations(Minimum acceptable scale. /w~= 11) __4copies
Plot/Landscaping Plans 4cnpimo
Color Photou(pmntof house&location of proposed work) 4copies -----
3, Gwnmmm|&Sign Specification Sheets:
k4a\oha|s to be used(including detailed descriptions of size,mty/e, and composition)must be specified, Color
chips for any color other than white are required, The only pre-approved color iswhite� all other colors must
be approved bv the OKHCommittee, The only exception io the use of colors that match those already umthe
structure and that were previously approved by the OKH Committee, Color phmdno(aee#2 above)are
required; "to match existing" should be noted on specification sheet, If material is to be left^nature|-
(unpain*ad)^ please include that information the sheet, Manufacturer's inform ation/broohurenfor
wmdowy, doono, garage doors,etc should be attached, Please note grid pattern and type<snap-in. between
glass,permanently applied,etc>fprvv|ndown, Skylights should have a flat, not curved or^bubb|e''. profile,
4. Abutters' Lists:
Map and Lot numbers for properties directly abutting and directly across the street from the work location are
required, Instructions for obtaining the abutters yNop and L*numbers can be found on the Old King'o Highway
Department pmgwonthnTovw`wmbmte:vmmw,yan/nouthma.us
CHECKLIST FOR REQUIRED APPLICATION INFORMATION:
1 NewBw�d|ng�mnm��cNaq [m ~ residence/commercial,mh�d �ew��mn�inmno,aAe. }� . , . ~ .
' _o. Certificate of Appropriateness, Specification Sheet, and Abutters'Lists
b, Elevations/drawings of all 4 sides to scale(Minimum scale accepted is 1/4' V)
PLUS: ^' —
--
Fmnewhouses or commercial buildings:
Topographical new buUdinQ s>, landscaping, retaining walls, exterior lighting,
and uh|ity8HVAChookups,
For sheds and other ouuiVambui|dmos:,
Plot plan&c4|c"photos showing location of new building in relation to existing building(u)
Color photos nf front ofhouse and location ofproposed building,
��\Adddimnm/#�mna�onm{ w mwn ��aohed�aranm.dormers,v|nvA siding,ne*�chimmmv`stairs,
\��'pon:ham/dwchs. w|nd --' —U .` mms.vWndowbwxww.mo�rpmoedm. lmnnppos¢m.eto.
a Certificate of Appropriateness, Specification Sheet,Abutters'List
h, Color photos showing front of building PLUS affected sides.
x. 8muhuoa o/manufacturer specification sheet showing type of window. sky|iQht, domr,solar panel,
lamp post, etc,
»� d, Elevations Vo scale required for changes to building's~bmtpri r necessary for windows,
doors, and the like UNLESS the location or mlae of bmmu on fa(;ade isnhenoinq. (M\n"nwn
acceptable scale is 1/4^= 1'>
m, Plot plan showing location cf new work relative to existing building(a) (Only required for work
affecting^haotphnt^of building, ag, deck addibonj
7� L For solar panels:An aerial drawing to show the area and layout design.
GENERAL SPECIFICATION SHEET
Project Address:
FOUNDATION: Material: Exposure(Not to exceed 18'):
CHIMNEY: Material/Color: GUTTERS: Material/Color:
ROOF: Material: Pitch(7/12 min) Height to Ridge: Color:
SIDING: Material/Style: Front: Sides/Rear: COLOR CHIPS
Color: Front: Sides/Rear:
TRIM: All windows&doors to be trimmed with: lx 4 1x5 (Circle one.)
Material: Color
DOORS: Qty: Material: Color
f . 4
Style/Size(if not listed/shown on elevations).
STORM DOORS: Qty: Material: Color
GARAGE DOORS:Qty Mat'l: Style: Color.
WINDOWS: Qty/side:' Front 5 Left Rgnt 1 Rear Color:
Manufacturer/Series cçrThLAM Material' \\I
Grilles(Required Pattern(6/6.2/1,etc.) 31t.9 Grille Tvoe:True Divided Lite: LII
t
Snap-In: Between Glass: 17 Permanently Applied: [lExterior n Interior
STORM WINDOWS: Qty: Material: Color:
SHUTTERS: Mat I: Style: Paneled Louvered Color:
SKYLIGHTS:Qty: Fixed Vented Size Color:
DECK: Size: Decking Mar I: Color:
Railing Mat'l: Style: Color:
WALLS/FENCES*(Max 6'height): Height Marl:
Style: Color:
(Show running footage& location on plot plan.) *Finished side of fence must face out from fenced in area,
UTILITY METERS/HVAC UNITS: Location: Screening:
LIGHTS:Qty: Style: Color:
Location(s).
LIGHT POSTS: Qty: Material: Color.
Location(s).
Additional information:
2-General
APPLICATION#
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TOWN OF YARMOUTH
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
ABUTTERS' LIST ... rcm - ",.
LI0 'ijz?
Applicant's (Owner) Name: 1 '' l(1 c
}
Property Address/Location: V1 r` \. ")r z ijIGHWA sy,
Hearing Date: 1
Notices must be sent to the Applicant and abutters (including owners of land on any
public or private street or way) who's property directly abuts or is across the street from
the Applicant. Please provide the Assessor's Tax Map and Lot numbers only, The
OKH Office will send out notices using the addresses as they appear on the most recent
applicable tax list,
Note, Instructions for obtaining the abutters Map and Lot numbers can be found on the Old King's
Highway Department page on the Town website:w rrvr. armou h.ma.us
Map Number Lot Number
Applicant Information:
Abutter Information:
133 31
133
133 021
133
133
Application #: �y
8.2018 3
The Commonwealth of Massachusetts
_
�� t
Department of Industrial Accidents
=/a= 1 Congress Street, Suite 100• Boston, MA 02114-2017
r;SY• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Tiffany Callahan
Address:6 Dauphine Dr
City/State/Zip:Yarmouthport, MA 02675 phone#: 508-641-6605
Are you an employer?Check the appropriate box: Type of project(required):
1.Q[am a employer with employees(full and/or part-time).* 7. ❑New construction
2.Ell am a sole proprietor or partnership and have no employees working for me in 8. ✓Q Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10❑Building addition
4.0I 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.QElectrical repairs or additions
proprietors with no employees. 12.[i Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.LI Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.0We 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: Arbella Insurance
Policy#or Self-ins.Lic.#: 93876400006 Expiration Date: 6/1/2023
Job Site Address:6 Dauphine Dr, Yarmouthport, MA 02675 City/State/Zip: 02675
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 the pains and penalties of perjury that the information provided above is true and correct.
Signaturg // ,' Date: -1/7/tea
Phone#: 5C (oy I - to(,;C.j
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.