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EXPRESS BUILDING LDING PERMIT APPLICATION
(OWN OF YARMOUTH
l armouth Building Department
1146 Route 28 RECEIVED
South Yarmouth, MA 02664 " �'"
(508) 398-2231 Ext. 1261 APR 2 2025
CONSTRUCTION ADDRESS: 1 G(>n
By. PA BUILDING , TMENT
OWNER: Way\Vl; -{-evt\noi n 2 i Ciro--' \V KOka t TIT
♦\\II PRESENT. Es ��""c EL1, .
CONTRACTOR. \T� 1 I
�� � U
NAME MA LING ADDRESS TEL.u
EMAIL: f .1 v y _ v v
Residential ``��J Commercial Est.Cost of Construction S i►aj � r.
Homeowner is Applicant? Yes No
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
Siding: #of Squares Replacement windows: # Replacement doors: #
Roofing: #of Squares Insulation Temporary Mobile Home
Temporary Construction Trailer Demolition— Interior only Demolition Raze Structure
Solar System ESS System Chimney Fencee44_ g pi- „pence_
*Please submit utility disconnect letters for electric & gas-- structures oN t-r ?S ears old reottire historical resles%
'The debris will be disposed of at: re k a C ✓6`)Ck—V U V 6(/ ' \v v/ `s' L VI 1-C
Location of Facility
I declare under penalties of perjury that the tatements herein contained arc true and correct to the best of my knowledge and belief. t understand that any false answerls)
will be just cause for denial or r v on of my icens nd for prosecution under M.G.L.('h.268.Section I.
Applicant's Signature Date: D1(L2/zoir(zzi5
Owners Signature(or attachment Date
Approved B).. Date:
Building Official for designee)
Rev 6 24
The Commonwealth of Massachusetts
i f 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
NOA
Name (Business/Organization/Individual): W', �✓1����
Address: Z\ ��w A po4 J
City/State/Zip: \kl LL 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.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P ty. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
35)I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
(L myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ 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 ce h' (C rider-the)pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 0-* `Z .2-0-)--
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):
10Board of Health 20 Building Department 312City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.❑Other
Contact Person: Phone#:
•
f
LEGENDA.
wil, ; 14
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OPP
X 9" EXIST.SPOT ELEV. Locus ` ,I �I
[99)-- PROPOSED LOMOUR �� ` ,
1.98 hE7 ',�
] PROPOSED SPOT EL j /
' `
cl, TE5T HOLE Yrp 1D /
2„ SLOPE OF GROUND
C > PARCEL 58 •� �1,�
nn A. SPRAGUE , ,..3. 1�f 1 09 .a pi
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UDLIFf POLE 122'
40
POE:NOT AU.TAMES MAY APPEARINonAWr o_ ,` E7(Isr.BLDG. d� /I O�, .�O 1 e+` \14
,..„...ve
, r--,44 1,4`0111111 MS
/I / LOT AREA 5000 SF
N� ;/ EXIS7INGI; �?' LOCUS MAP
t DWEWNG /
_J //1TOF 17.6 / NOT TO SCALE
t I/1 / /)�� I ASSESSORS MAP 49 PARCEL 57
\ i ;y,♦ ',�/ 1 r'I ' /10 `� PROPOSED BUILDING COVERAGE: 18.9%
PARCEL 52 ♦'♦♦ ,�� i/1
'n/LhL QRITTON J' ' " 7V �♦
t. ♦ y'♦ •' g SITE PLAN
♦v��~`*�♦ ! O! PARCEL 56
♦ E x , ♦ O
♦ ♦ ♦^ A.O nit.L 4EEiAN OF
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NOTES o
s °� l)✓ �� 21 CIRCUIT ROAD EAST
WEST YARMOUTH, MA
I.DATUM Is tlA_AMEflei
PREPARED FOR
2.THIS PWI IS FOR PROPOSED WORK ONLY AND NOT TD PARCEL 53 1 �--..♦ . 1. 1-...'
BE uSED Far LOT UNE STAanG CR ANY DTHER n/1 W. WwASZEK PROPOSES o
PURPOSE. NANCY BRENNAN
a CONTRACTOR SHALL BE RESPCNSEiE FOR CAUJNG \ 96 sf M1°
=SAFE(1-888-344-7233)AND VERIF•ING THE SHED �' �-
LOCATION OF ALL UNDERGROUND#OVERHEAD UTILITIES DATE: SEPTEMBER 25, 2017
PRIOR TO COMMENCEMENT C<WORK EXIST. BLDG. REV: OCTOBER 3. 2017 (SHED LOCATION)
4. EXISTING SEPTIC LOCAnON PER TtE-CARD ON FILE
MST. BLDG. I _-_�
1NM TOWN. PARCEL,.5S4...
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( 0 20 30 40 EG FEET YARMOUTMPORT MA 02675
DCE #1%-220 DATE DANIEL A. OJALA. P.E., P.LS. 6-221 CC SfPT1c-CONsnrunoN.ORG