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HomeMy WebLinkAboutBLDX-25-537- RECEIVED Yq )flice Use Only �� ' o APR 2 5 2025 — ..5 - 3 Permit# v0 - /.� Amount ',I .,....4“.1 4r, BUILDING DEPARTMENT .. I3y: L °9PORfT EQ‘ no f EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRt('TION ADDRESS: 2A (P A- y cL^.+ti-4,.. ?vvl , . f'} ©2-L i 2v1 PT- Cvft f j 1? OWNER.la-N- 0-1..=Tt~. LIG.-4-f,1 /�S�u ��€'`.-, 6d56 -�l 2_- �-1( 1 • \VI PRESps.r \DDkI '' TEL. # CONTRACTOR 4-4.....,_9{-es,ke._ t -( (5 i'e...e..- fo000 =tFFis Pku.e...— _.._50g_- J0" - L 3oo NAME MAILING ADDRESS`T' 6- Al,,.2— r 1nott TEL. 0253- EMAIL: _'Residential Y.Commercial Est.Cost of Construction S Homeowner is Applicant? Yes No Home Improsentent Contractor Lic.# Construction Supervisor Lic.# -e- tj, Co('2--1I2S l `"'\ 6(� �°' / � \\ORK TO RE: PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows: u Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition-Interior only Demolition Raze Structure Solar System ESS System Chimney. Fence *Please submit utility disconnect letters for electric& gas-structures over 75 years old require historical review *The debris will be disposed of at: 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 l understand that any false answers) will be just cause for denial or rccocatio�te!n of my license and for prosecution under M.G.L.Ch.26X.Section I. Applicant's SignaturL Vi\ ra Cp, % .W-ci( -) Date: i-1 2i' +12�J Owners Signature(or attachment) 5\v.fo( @ itµ�1e. C, ,,,,� Date: t Approved By: Date: Building Official for designee) Ren 6 24 .\ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New❑ construction listed on the attached sheet. 7. ❑ Remodeling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance pomp. insurance.t 9. ❑ Building addition required.] 5. D. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 petjury that the information provided above is true and correct. / Signature: yl,\Alb I k— Date: tE-t2.S`2 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(check one): 11:1Board of Health 20 Building Department 312City/Town Clerk CO Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: ,MAR-04-2018 22:01 From:5085634571 Paee:272 IMPORTANT DOCUMENT Certificate of Flame 1@tstance ISSUED BY Date of Shipment 11/7/2017 piCINIOR.DUSTRIES INC. Sales Order# S0-652496 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described are inherently flame retardant and were supplied to: 76980 BARNSTABLE COUNTY CORRECTIONAL FACILITY 6000 SHERIFFS PLACE BOURNE MA 02532 USA • FLAME RETARDANT Registration Number: SNYDER MFG : 4-5TE1� F-14001.01 & NFPA 701 & ASTM �a=orc �.ci;�'`;F E84 CLA r u~i ��� 7. Fabric meets requirements of Certification is hereby made that: )-he articles described on this Certificate have been treated with a flame-retardant approved chemical and the application of said chemical was done in conformance with California Fire Marshall Code. Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For the Life Of The Fabric Serial# 8002102(1) Description of item certified: FIESTA TOP 20WX40 WHITE SNYDER SNYDER MFG �uIG« (��i Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC Untitled Ma „, , f • • � ' Legend J • ,i 41J' '"" ,---- .. Y ` ..'`4.,r' !E •x 297 MA-6A Write a description for your map. ', f,� ' ' �, .�,. � - ,- #� • `0v•�. ' ',,�' r' Yarmouth Port Library sue.,-._ ' • �:mi • l' "r�+I� T ' ,:.• -..1.r r • ° < a . +tc,iR 1� *4 ` .ems a3 t `y''4 , _1 If - , c• 16 f ' r''''' - If ' , . .,.. �y ram" z la Ill i ..rt - �' h ,44 m C�'.�`a. ••., - , • k,T-�a„A,d w 'J ,' . ! . r1�w�1 j•;ar "�'. ^^ r vv h a� �, s j•� 3 ,. + Fy _ ..,. �.}, °a• m' e -, `AL. YaimOutl •POrt.L+bf2 j 1 ` . 'rr ' 3► g} *� * ' „1'3 NNNii4 r . r ..• •. x' ter : ''" 297 MA-6 `i A . A ` b h , 3,I y •PAS 1 V r } qkr• T } t t r } .•--'' L " jM ►, Y* • ae 3 H A.fit A . M } .< .... t , Go:. �t ,. r,rth N