HomeMy WebLinkAboutBLDX-25-1483 foY''a RECEIVED D .eUseOnly
NOV 0 4 2025 Aunt S
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508)398-2231 Ext. 1261
CONSTRUCTION.ADDRESS: //7 Sd/9Me.f ' 6.7 Y/VrPe/00171✓Pre.r
OWNER:_-ase"Pt/-.7Jice -*/'7p2ox.
\:\MI. PRESI'SI \UI>Rf SS TEL.+t
CONTRACTOR: _25.4//D ear PdBair y1/1 _s5.o YAM) ,S'ofr f/oL S-20
NAME /� MAILING ADDRESS TEL.a
EMAIL: .sPfeei ed�' /—Y/QAthV-Lr'Jt'''J__..
)/Residential Commercial Est.Cost of Construction S &AOC&
Homeowner is Applicant? Yes No.
Home Improvement Contractor Lic.# /1:40'449-2 Construction Supervisor Lic.# 0/e3 - .
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_ Fence
`Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical review
'TN:debris will be disposed of at: y� ✓/0//y/f
Location of Facility
I declare under penalties of perjury that the statements herein contained arc true and cortect to the be:t of my knowledge and belief.I understand that any false answensf
will to just cause for denial orres •alien ol'my license and torprosecut der.1.t i.L.('h.2Aa,Section I.
Applicant's Signature: Date: //3/26.--
Owners Signature(or attachment) —1f Date: L L S^
Approved H} Date.
Budding Official for designee)
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ROUT 28. SOUTH YARM U H, tom, 02, xi 1
b� Telephone ( 8 398 2231 1 92 Fax )8 -0836
OLD KING'S HIGH .. .:AY HISTORIC DISTRICT COMM '.E: -' ; District
xti' APPLICATION FOR
Application is hereby made for the issuance of a Certificate of ExemptOon under Sections 6 and 7 of Chapter 470 of
Acts of 1073, as amerced, for the pfoposed wok as described below arid on plans, drawings, or photographs
accompanyirig tilts applicatiort
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Ali apOications mud be submitted by owner or accompanied by letter fr�i owner approving submittal of application.
1ailirg address: i -) ' ' " ' e'"'' 't A r��w;� ',.. '� 'k r'.`." 0 ( V :.I,b di: ,.. ' " ,..
r i it: r e � C, .�3 c C. �.. P ad r otificat n method: ... Phone °` Email
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Meiling ddress: ' „ rjry ,,,. 4 C> ' () • ;tCA, rtov1,0 0 , IN, il k 0 2.. .O 4
F „'1: <_i 1 (-1 'a A C ar-4 ) yi a 'A Y C" ri\ Preferred notification method: ' rJ Phone reran
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Date: i C.) i 2_,..9 I t„,5
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* Cvmatl t tc'oflag is aware that a wit may be to red from the Bering Department.seas. (C other department& alto)
0, Thit tedifItate 33 2oed tof one year from approval date or :ran date of emar 3r 0t 19 a43i Pests, ykkhevrei date s?ai be tar
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Historic District
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Date ram: i # ned �. +\11_ _._:e_ , _. _w - APP UCAT O #'
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TOW OF YA 1 II UTH
1146 ROUTE 2S,SOUTH YARMOUTH,MASSACHUSETTS 02664-4451
Telephone(508)398-2231 Ext. 1292 Fax(508)398-0834
OLD KING'S IDGIIWAY IDSTORIC DISTRICT COMMITTEE
WAIVER OF 45-DAY DETERMINATION
The applicant applicant s agent understands and agrees that due to the current declared National and
State public health emergencies the determination of our Application for a Certificate of Appropriate
ness Demolition Exemption may not be made within 45 days of the filing of such application.
The applicant agrees to extend the time frame within which a determination is to be made as required
by the Old King's Highway Regional Historic District Act.
SECTION 9-Meetings, Hearings, Time for Making Determinations
"As soon as convenient after such public hearing; but in any eveni $vithin fortyliye(45)days after
the filing of application or within such fi I rther time as the applicant shall allow in writing. the
Committee shall make a determination on the application.
Applicant understands that the review of this application will be scheduled as soon as the situation
allows.
Applicant Agent Agent Name (please print): I, \-../ I) ic...k.
,,-;--...--------, k
Applicant Agent signature: Date 10 /ZS/ L 1
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Y‘ciff)fivilli ' i'31
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GC; 3 1 7P,7;
Old King s 1-i)gliway 2 5 , ,
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Histotic District
Sherman, Lisa
From: CYNTHIA L Ecker
Sent: Thursday, October 30, 2025 5:08 PM
To: Sherman, Lisa; Bob Wilkins
Subject: Re: 25-E100 17 Summer Street
Attention!:This email originates outside of the organization. Do not open attachments or click links
unless you are sure this email is from a known sender and you know the content is safe. Call the
sender to verify if unsure. Otherwise delete this email.
Hi Lisa,
This exemption is approved.
Thanks,
Cindy
On 10/29/2025 3:40 PM EDT Sherman, Lisa <isherman@yarmouth.ma.us>wrote:
Hi Cindy,
Residents would like to replace their roof at 17 Summer Street.
Please let me know if you need any additional information.
n\
Thanks Cindy, / u
(
Lisa
J ., ,:ijnway
; 1 morfc, District
Lisa Sherman
Town of Yarmouth
Administrator, Old King's Highway Historic District and Yarmouth Historical Commission
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
P._-
: =y Office of Investigations
Gii - Lafayette City Center
tl}"'�A 2 Avenue de Lafayette,Boston,MA 02111-1750
b..:� www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
Name(Business/Organization/individual): 7jj0//,.n ( -
Address: /4 Gd?liG7Dt7)5-ie Gh'
City/State/Zip: Zi> it /)7A7 G7; 3 Phone#: SUS-94 7-•52M'
Are you an employer?Check the appropriate box:
contractor and l Type of project(required):
1. 4.I am a employer with / ❑I am a general
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' g ❑Building addition
[No workers'comp.insurance comp.insurance.
required.] 5.❑ We are a corporation and its 10.0 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®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: j/..471Io/LJ2j
Policy#or Self-ins.Lic.#: Expiration Date: 7,i(/2 C,
Job Site Address: /72.Sl h?,577 C7 City/State/Zip: yh/4,-71 Ci/lJy
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 te�nder thepains and
e penalties of perjury that the information provided above is true and correct.
Si ature: Lli 4rG7i Date: //�/,2�
Phone#: Jd 9-9t — .5.P. /
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 2❑Building Department 30City/Town Clerk CO Electrical Inspector 5D'lumbing
Inspector 6.0Other
Contact Person: Phone#:
THE COMIIICNWEALTH F MASSACHUSETTS
Office of Consumer Affair dtici Business Regulation
logo Washingtt tr t..= Suite 710
Bostarl t -118
Home Im o .
pktration
..- "
?'' f ,��r,.. t..l kM.-... .,,Type: Corporation
DAVID COX INC "ii '`� ' -,N`.=`,./ F cation: i31224t?02n
19 LAVENDER I.N 1;••— . r «' : ,
W YARMOUTH,MA ;12t 73 so, ;,;-.: :..: 5 :,; 1.4..
1r.;, 'Y ,'/
:",�:;... 'f ;Jobe.*Audreva and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Ceneurner Atft,ltos;&Business Regulation Registration valid for IndMdual use only before the
HOME 161PROV� ONTAACTOR explratIon date. If found return to
Office of Cotneumer Affairs and Blr*uete Regutatloo
1 i'. {'A1k ► 1040 Washington Street -Suite 110
, A1 , -3T'� Seaton,MA 0211E
11AVID C')X, INC: ,,..•• y '„r.::,�., "rs...
DAVID R.cox ,, ' 141,,:+ 7.r l e 4:`r' r',,,>'.t'
w.YAf1t ?U?H.MA O�t:'r9. .' s Undfxsocrotary Not valid without signature
noreplylicensing@mass.gov
Your OPSC License has been renewed
Aug 27, 2025 at 10:35:28AM
drcinc87@yahoo.com
THE COMMONWEALTH OF MASSACHUSETTS
DIVISION OF OCCUPATIONAL LICENSURE
Office of Public Safety and Inspections
xww,rims.g pi
August 27. 2025
DAVID R COX
PU BOX 401
South Yarmouth MA 02664
Your license CS-063537 has been renewed. The status of your license can be reviewed on our verification
site at vffiitication (syliccnse.cstv.).
Please see the attached copy of your digital license. OPSI Licensing is no longer printing and mail in4, hard
copy licenses.
Please see the :!-a te% �'51�.. i;11 L icetb,;y and Fre oelxtly Asked Question-. Carrying a Digital License is
deemed the equivalent of carrying a Hard Copy License. As a reminder, a Digital License or a Hard Copy of
your license must be furnished for inspection immediately upon request by a duly authorized individual.
Me ise note that the OPSI Licensing Portal My, License One (t1ML(l" also provides access to a digital Vers+(,7,
d root license. Please read thejoi) oid for step-by-step guidance for how to view/print an Office of Public
• Safety and Inspections (OPSI) License. If you have any questions,please contact us at ups i-irtfo(.u•tt.tis,
Regards.
Licensing Unit
Vt:mm�tonwealth of flanssa husetts Construction Supervisor
.- Division4f Oczuptrtioncl Lice3nsur. Unrestricted-Buildings of any use group which contain less than
Boatel of Building Regulations and Standards 35,000 cubic feet(9%1 cubic meters]of enclosed space.
GS•463537 tlpire 10/15/2027
DAVID R CO*.. ��` .s "k KRRk
PC)BOX 401/ sa n� :,
SOUTH YARg9UTHM/1 *8pt "r s 4,11
't failure to por,sess a current edition of the Massachusetts State
Building Code is cause for revocation of this license
,.:n„wt t:s ioner .f r Contact OPSI:(617;7.7.1200 or visit www mans go:idpllopss