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Home My WebLink AboutBLDX-25-1039 Qf,Y_ARA +y,' RE C E Y !9 E_D t Office Use Only � • lt7 AUG 1 2025 Am-, BUILDING DEFARTivIENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department • 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231/ Ext. 1261 CONSTRICTION ADDRESS: ,_ j}-t,(.�� .SQ Gl J/ U e ,......--- OWNER: !�'`a tAit� ,� Mar r¢-7 9It >i 50 J Cuk Sot J03-1 t0-3i. 6 \\\II I'RI.S4\I:%I)11RI SS TEL.a C'ONTR:\C'T(IR \/\\II \I MI[Mt\I)PRI SS TEL.a _- -- 41,..../.__ZI ,�RCsidemial :Commercial Est.Cost of Construction 5 I �'_ Uv v VVVVVV ' --- __. Homeowner is Applicant:' l'es t-/ No Home Improvement Contractor Lic.tt Construction Supersisar Lie.ft WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:k Replacement doors: It Roofing: #of Squares Insulation Temporary.Mobile Home Temporary.Construction Trailer Demolition-Interior only *Demolition Raze Structure Solar System ESS System Chimney. /Fence V •Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical res less 'The debris w ill 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. I understand that any false answerlsl will be just cause for denial or revocation of my license and for prosecution under MG L.('h.26R,Section I. Applicant's Signature T Date'._ Owners Signature for attachment) �j�4/7 Date: 8/ii/ C ✓ Approved Hy- _ Date: Building Dlliccrl for designee) Re.b 24 The Commonwealth of Massachusetts Department of Industrial Accidents _;, ► Office of Investigations sRf Lafayette City Center ='tors Lafayette,2 Avenue de La a ette, 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): .f rr 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 comp. insurance.] 9. Building❑ addition r red] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.0 Other 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 arc 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 pedury that the information provided above is true and correct Signature: ZII / Date: 8 Phone#: l( 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 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation tier their employees. Pursuant to this statute. an employee is defined as "...every person in the service of another under any contract of hire. express or implied, oral or written." An employer is defined as "an individual. partnership. association, corporation or other legal entity. or any two or more of the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer. or the receiver or trustee of an individual. partnership. association or other legal entity. employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein.or the occupant of the dwelling house of another who employs persons to do maintenance. construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152. !;25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required.- Additionally. \tGL chapter 152. 25('(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and. if necessary, supply sub-contractors) namets). addresses) and phone numbers) along with their certiticate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the members or partners. are not required to carry workers' compensation insurance. Ilan LL(' or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit license applications in any given year. need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on tile for future permits or licenses. A new affidavit must he tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to anv business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address. telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Revised 7-2019 Fax (617) 727-7749 www.mass.gov/dia ' 'F I° 1FE \ If.' ,Q '% ot"� _. -\;, �" 14..4... l",''.4..'' }t,-'.3' 1 _ y7'..a r..." may! ORDER NO. *. SALES AGREEMENT A, FULLY INSURED Et BONDED _-., �1�t'iri' t,l' www.profer,ceco.cOrrt DATE11 • CO• Q 133 UPPER COUNTY ROAD• SOUTH DENNIS, MA 02660 • (508) 394-4800• FAX (508)394-6735 , U 835 WOBURN STREET• WILMINGTON, MA 01887 • (781) 933 1234 • 078)657 54t0 FAX: (978)658 9932S '` `k -"4- INCORPORATED NAME SHIP TO STREET v\ t l Th t r''. . X`� f t STREET t CITY STATE ZIP CODE --a `' r r T \ L---•� 5 a.pi, P--., air v r',, , : ----- - CITY 4 STATE ZIP CODE INSTALLATION HOME PHONE BUSINESS PHONE � P. A I A .0, ',�,�__- TELEPHONE fi '�� `� t E. @ ;; e/ f�,� ? ', ; y NOTIFICATION ' �_-�— STYLE NO.OF RAILS i HEIGHT ,ter1. L < �, ._. • ON YOUR PROPERTY IN ACCORDANCE WITH QUANTITIES AND LAYOUT SHOWN BELOW QUANTITY 4 DESCRIPTION UNIT TOTAL 4e r f . !.. (29 11--:-L\ k (,--‘__ kf.,,,. "S: • 4 ` .`. a , - e-i. • , ,-, I. f DEPOSIT l TOTAL SA --- BALANCE On Completion , TAX • -.. ----------_. . - -- -- TERMS TOTAL ONE HALF WITH ORDER BALANCE ON COMPLETION LAYOUT INDICATE ON LAYOUT PICKET FACING ON EACH LINE OF FENCE. CHECK LIST ..-.-t; _ CLEAR FENCE LINE (" ;r �"Y TRFE/STUMPS T-:--_.._._, -,, TAKE DOWN EXISTING p F. it r ` FENCE STACK ""1-*! ,, '' A,. BUILD SECTIONS I 1 4 o I ON JOB = µ, ! TOP OE FENCE TO -4-w i1,4_ FOLLOW GROUND : 1 -,. - Racy SECTIONS 1/ - -- 3 r STEP SECTIONS f. (/): ., CtJRVE SECTIONS -`i i FACE FINISH I ' I, SIDE r. T BARB TOP —. '" // -� KNUCKLE.TOP [Pt - (1-71 I �.- f fi` UNDEKGnOc3Nl3 i PIPES OP.CABLES ,$RING COMPRESSOR -L. 1 ''' r (...,, ) ._ ,j'i; GATE SCALLOPED t_ GATE STRAIGHT - r f t ERECTING CONDITIONS GALVANIZED OR VINYL TAKE AWAY OLD FENCE ,:Ji quotations sibiect to conditions beyond our control. CUSTOMER IS RESPONSIBLE FOR establishirx;property lines and fence tines, and for conforming with local zoning by-laws. Pro Fence Co.. Inc-, is not sesponsibie for a ,to underground utilities, septic sole--ns, drain pipes,or propane Tina<.. unless notified in writing by the Customer as to their Location, before work is staled This quotation does rut include costs mint in a treorcdinary conditions-striking ledge which may require the cernentinti of posts or the use of a cn:npre:sor for drilling and pinning posts,Or Gearing trees, hr;.+srti or airier obetnr Lions from the woq.iri area. This rOrttf(1 E%nbodies the entire understanding bet-ion part:es,arid there are no verbal agrc+crnents or representations in connection therewith. All ft%-i a Materials rehleirtt a 'ty 4 Pro Fence CO., Inc ,until/pal payment has been made. By signing this agreornenl the c,Jstomer gives Pro Fence Cn , Inc, permission to enter the properly anda rnitMi Worm ell fence rnaterr�i: final payment is riot recer-i'e BY '_ _.___ -_ -. _ ACCEPTED} by _ --__ _ .____ rill rr- 'roc fivA, ZA t{trv¢ 4-rnan,,,,r -r-nett pro r;,mry ear(al a twnrefir r tF,nr . 0bb net.mnnth-Annual rate Al IA%-Plus env adIStinnal r.ri is ii i trier{fru collection inckxlinn ren4Tn,hie Attnmevs lees fin. ORDER NO. SALES AGREEMENT / ,, � , FULLY INSURED Et BONDED ) ' ' `,)cat_ II II k toir www.profenceco.com DATE . FENCE CO. U 133 UPPER COUNTY ROAD•SOUTH DENNIS,MA 02860•(508)394-4800•FAX(508)394-6735 h' INCORPORATED 0 835 WOBURN STREET•WILMINGTON,MA 01887•(781)933-1234•,(978)657-5410 FAX (978)658-9932 5!' D-L " NAME SHIP TO STREET r STREET CITY - STATE ZIP CODE r CITY i• STATE ZIP CODE INSTALLATION HOME PHONE BUSINESS PHONE IM -r r \ TELEPHONE `1 -,, t ,`,o r r . � � 1 NOTTFrcAnoN C j " c i Ur v [ STYLE C� NO.OF RAILS HEIGHT L ON YOUR PROPERTY IN ACCORDANCE WITH QUANTITIES AND LAYOUT SHOWN BELOW QUANTITY DESCRIPTION \r. UNIT TOTAL it it Y Y • IMPORT TOTAL SALE --" Z-, °.N%.\0 j BALANCEA* I On Completion____ TAX i V \) TERMS TOTAL 18 ONE HALF WITH ORDER BALANCE ON COMPLETION I LAYOUT-INDICATE ON LAYOUT PICKET FACING ON EACH LINE OF FENCE. CHECK UST "1 '--" r CLEAR FENCE LINE !r"' f\^- - -, i Y ----�• UMPS L _ ` i — TRIM ENCE LINE TAKE DOWN EXISTING T _ -� / FENCE STACK I t I !, BUILD SECTIONS t - -� . 1 t, ON JOB r f y TOP OF FENCE TO I FOLLOW GROUND �_ (. ,)t RACK SECTIONS t- STEP SECTIONS L CURVE SECTIONS fFACE FINISH SIDE �RB TO NUCCKK K LE.TOP L' �' y UNDERGROUND T PIPES OR CABLES BRING COMPRESSOR I , GATE SCALLOPED i - i GATE STRAIGHT • ERECTING CONDITIONS GALVANIZED OR VINYL > TAKE AWAY OLD FENCE All quotations.sc±laet to conditions beyond our control CUSTOMER IS RESPONSIBLE FOR establishing property lines and fence lines,and for conforming with local zoning by-taws Pro Fence Co., Inc,is not fesponsible for demage to urQercypurd utilities,septic systems,drain pipes,or propane lines.unless notified in writing by the Customer as to their location,before work is started.This rs criterion goes not include oasts mot in eictreorclina y a.,nhtions-striking ledge which may require the cementing of posts or the use of a compressor for drilling and pinning posts,a'deeming trees. G sh or other obistruciians from trio, rng`area thi con tract ntract embodies the entire understanding botwer r parties,and there are no verbal c-p:eements or representations it connection therewith. Al fence rarenais renpiist eB optrty Fro Fbrre Co.,Inc ulhttinal payment has been made By signiny this agreement the customer gives Pro F ence Co.,Inc.,permission to enter the property ems er d e any-or 0fence reefeyrts `final Went is not recerv£f _ ,_. -- --ta1 - _