HomeMy WebLinkAboutB-12-1327Uttice Use UNy
13 Permit
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expires 6 months from
date.
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28'
South Yarmouth, MA 02664
�j
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 495 1Z(VF 12 RF A4'.0 ha n v►.I r I A r- -, r c
ASSESSOR'S INFORMATION: 6701 X 10 I TEW- PKOVI pC p Fdf� �� y�4KM�UTH SUMMER rCI ct1
�'1`1 Map: e�6 Parcel:
OWNER: I V W ►v O F ' c
NAME PRIiSIiNT ADDRESS J _ .•• #
ThI"A
kcx-o�
'9-a3(
CONTRACTOR: AR N ST I Ch 1( ( F 6 Doti S i
NAMEplq� cr► F S s Pi4(�rM I� fff, S FL . 131i �(O�A�i 1�t}
Residential Commercial Est. Cost of Construction S 14
Rome Improvement Contractor Lic. # Construction Supervisor Lic. #
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insuran e Company Name: Sri,G Fatz Worker's Comp. Policy#
WORK TO BE PERFORMED
Lent (Iire Retardant Certificate attached)
Duration Wood Stove Shell
:; Siding: # of Squares Replacement windows: #
Replacement doors: #
Re -roof: # of Squares
O Stripping old shingles*
`The debris will be disposed of at:
I declare undr penalties of perjury that the s
will be just cause for denial orAoeation of
Applicant's Signature:
, Owners Signature (or
Approved By:
Buitdin,o Official (or designee)
O going over layers of existing roof
Location of Facility
Old Kin,s Highway/Historic District
RoofmP/Siding (Like for Like)
herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
I. v
Date:
777=
i)atr•
Date:
Zoning District:_ f( °- 3 _
Historical District: Yes Flood Plain Zone: es
Water Resource ProtectionDistrict: Within 100 of Wetlands:
Yes A. No
No
The Contntonweafth of Massachusetts
Department of Industrial Accidents
Offlee of Invesdgadons
600 Washington Street
Boston, MA 02111
IV www.m4mgov/dfa
Workers' Compensation Insurance Affidavit: Builders/ContractomiElecMctans/Plumbers
Applicant I floe tease Print L
eWb
NamNam-S��A�'odlndividwl):_%CMMo#jItIE./iLTN aF_Lift£�Q-�-��.T.i'��1�.KA�s.�$1���U�IT�
Address: boon Sii'F9 4 GG S Pi nr,
City/State/Zip:_VO U R k E D asy'�a Phone #: <i ll R / 5-13 - 4 3,ln
Are you as employer? Cheek the appropriate box:
1.01 employer with 4.01 am a Sena ontractor and I
etrP and/or part -thus).' have ' the sub -contractors
2. ❑ I am a sole propri
ship and have no employees
working for me in my capacity
[No workers' ::,7w
e
3. ❑ I homeowner workmyself [No com.
iaaurance 1 t
lis on the attached sheet
sub -contractors have
employees and have workers'
5bcomp. insurance.t
S. a are a corporation sad ib
o have exercised their
right of on per MGL
c. 152, $1(4), we have no
employees. [No
comp. insurance re
TYPO of Project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. 0 Building addition
10.0 Electrical regain or additions
11.11 Phing ing repairs or additions
12.0 Roof repairs
13ROtber lur
•My appNgptt dui chain box 01 no a m fill nut the section bebw l
t Homeowrun who submit dds affidavit ' altow6td dteir worker PoNCY ildbrntatlae.
rndiadtt� they am doitta aU rvott and dim him auuide contractors must submit a new affidavit indk8dna such.
tContraatom that clreclr this boa roust attached as addttiand sheet ahowina die rums of dw wb.camactars and stets wbedw or not thus entitip errptoyses, tf the subtonowto have empbyns, twtrov
hey mProvide a,* wo*=' comp. poBey number. hays
deft ISYM that t`pr•v �t to Workers
Ino.naf compensdaM h"MrMW f r err ►"M MOW Is A& poNCy exdj4 else
Insurance Company Name• r o `I
Policy # or Self -ins. Lic. #: (� u�
��F=,-h,J.� .��• ExpirstionDate:
TY
Job Site Address: City/State/Zip:
Attach a copy of tin workers' compeusatlon policy declaration page (showing the Pommy nsnnber and expiration date).
Failure to secure coverage as required under Section 25A of MC
L C. 152 can lead to the imposition of criminal penalties of a
fine UP to S 1,500.00 and/or one-year imprisonmera. as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Oj&c of
I do hereby cenft rnder Of pen eperjrry that the wonnedon prarldsl above 6 truss on[ consul
Si n ,
P #• 7 —
use on o nw write In thkarea to cooly c ar town o,Q'klot
City or Town: Perrdt/Llcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityll'own Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone 11.
t''r3-pL����IMPORTANT DOC..
Certificate of VIanle
REGISTRATION
APPLICATION
NUMBER
F12L4
�NE NT��������
Resistame
ISSUED BY
Date of Shipment
NNDUSTRi�3r iNc. 3/1612007
EVANSVILLE, INDIANA 47725 Tent Identification
MANUFACTURERS OF THE FINISHED 04459337
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated
(or are inherently noninfiammable) and were supplied to:
76980
BARNSTABLE COUNTY CORRECTIONAL
6000 SHERIFF'S PLACE
BOURNE MA 02532
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California
Fire Marshal Code. All fabric has been tested and passes NFPA 741-99, CPAI 84, ULC 109.
Serial # 8002100 i 1 f
Description of item certified: - -
HESTA TOP 210W 40 WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
JOHiv BOYLE STATESVILLE KC Sic ftp�
Name of Applicator of Flame Resistant Finish�� {
aH _ —._ -
ANCHOR INDUSTRIES INQ
SITE PLAN
BASS RIVER BEACH
SOUTH YARMOUTH, MA
AM 26-116
150
Feet
N
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POND 8.8
W
7.6 E
7 7.1 7.1 $
N cp
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N � N
14.8
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14.3 10.� 1
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16.0 "FSt.6.-� " 11.2
� 16�0 - '
10.2
14.4
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15.3 ;;: BASS RIVER BEACH
6.0
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118
6.3
NANTUCKET SOUND
SITE PLAN
BASS RIVER BEACH
SOUTH YARMOUTH, MA
AM 26-116
150
--� Feet