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HomeMy WebLinkAboutBLD-23-000548 01•YRR tit) Tw" Office Use Only . O �1 �f` Permit a� 0. - . . lJ r l3/V2 ;Amount J Q.o0 %MATTACM CSE� •• ".`mob�J�, I Permit expires 180 days from I issue date 6 0-0Z3 -gO65i/' EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 [ m- -—-- South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 AUG d 2 2022 CONSTRUCTION ADDRESS: 4 rYfl 1,-- � Rd.' `''Z Q, 74h . BUILDING DEPARTMENT ' � Id ASSESSOR'S INFORMATION: Map: / I �{ Parcel: / G OWNER: 7-X 0h41 QS 4/V O ke, V&•1 ae.dlLy/ 7i.5--W, YY,rvnOG.4CIe. 0243- 13 g'9 NAME n PRESENT AD ISRESS TEL. # CONTRACTOR:/'> 0 Cr/n l 7/rp kt F c g t n15, 3a p 4/4/ of al $ 11// H y q rt r1 .t S' /f¢ NAVEC MAILING ADDRESS AL. 7 L L - r/r 7-talc/ I Residential 0 Commercial Est. Cost of Construction$ tr 000 `f Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) KI am the homeowner 0 I am the sole proprietor 0 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 k Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: y, ,, 0 i' 4 , t2 W'il 60 Cc- p t ra 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 rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: s i I a Owners Signature(or attachment) Date: ' a i c Approved By: 6 Date: -----5 Building Official(o sirs EMAIL ADD ) CO'4n G if yl �lJ4-tocd[se.ejriyl Zoning District: !/ Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: • 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts _ *47411= Department of Industrial Accidents IKE 1 Congress Street, Suite 100 " = �mom Boston, MA 02114-2017 owswww.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): 771 Ln 5 CO Address: q /5 �l/ . a v-- vg, (c/ , City/State/Zip: 7 C-vtM. a •f P -phone #: G3 q 5' ---j c{ q.5 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 _I am a sole proprietor or partnership and have no employees working for me in 8. n 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.]' — 4.4I am a homeowner and will be hiring contractors to conduct all work on my 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.❑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.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ Othe5) 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 verification. I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct. Signature: ' 2-�'r/.L - Date: g-/a- a Phone#: l� 3 " 3 cf _3 S 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#: - — ... ,..., TOWN OF YARMOUTH tiif. -Al :AI. • 1-------- 1 1....-s, 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 Telephone(508) 398-2231 E . 1292-Fax(508)398-0836 RECEIVED Aoc, 0 2 202PL I KING'S HIGHWAY HISTORIC DISTRICT COM ITTEE--- AUG 03 2022 , ,hkimouTh APPLICATION FOR -, luiKINGs HIGHwAY CERTIFICATE OF EXEMPTION BUILDING DEPARTMENT By Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: -- , C t - 0 je,... Address of proposed work: 7/5 It/ /6- t,- 4'7- 1-A )gCl:4 Map/Lot# I 1/1) ------", / Owner(s), / Pi 0 Ykt C•iy Ss (i—/1// /C t/4_ 6©#1 I?r(/y phone#: :,90 Y -Y." --.1V1-3-- All applications must be sulrlyedi by owner or accompanied bAizer from owner approving submittal of application. Mailing address: T15---- kv, yo VI II4 0 GC, 7—4 /V Year built- / 9'62. Email: Ile_0 h "i.it, nits, 513 c9711a l'I Preferred notification method: A Phone Email ' • ' A' Vai) ' Apent/Contractor: 4i.c.A .--.' kc\i ‘01A - C%f\c/ 11\)C, Phone#: 774-4// '(eC/ Mailing Address:3,2,14 - )4 3 . wit\ 4 /11 ilyanni.5 . MA excl , Email:HDC( t C ., ,,, PNA, , e gry) Preferred notification method: Phone X Email Description of Proposed Work(Additional napes may be attached if necessary): Re, (a c e 02 47/-47 c/o 4,-15 0 ii So 4_ 74/2 5 ( We a 7e 110 a S. The it/ 1 n 4 I a teS co n LI a /iie ,5-edet2 kv n2 ct iile 5/f-ee i be cQ se ii i- , es ,i) /4k/1(z-a ii)/ a -ft- c e . Signed(Owner or agent) Date: g ' • - )p- Owner/contractor/agent Is aware that a permit may be required from the Building Department.(Check other departments.also,) ), This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later, for Committee use only: Date: ')?I 22- /Approved Approved with c -----D,erqed . . . ., Amount 20 ti) Reason for denial. Cash/CK 0: #223 0 2 ,. Rcvd by: 1e4 t,,RtiI0t}i I LOLD KING S HICSHWAY Date Signed: S17/ 0.1- Signed' Cet" Z4121,te.4).4 f.441e 1 1 APPLICATION#: 692•-r.NI V5 2017