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Home My WebLink AboutBLDX-26-1203 application RECEIVED t c7) �.,.�__ Office Use Only ;, O Permit#dWk"ako-1czi5 . : , -,y r000126 Amount 7 �NMAT.KML[3[ \\� ,�9: BUIL RTMENT °,fooRATE�� By' EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ` �Z y .A , V---V\ ti o 3 OWNER:\ '‘ �,or%"I't teaS %acre. 8S 3Je. 11A - 0_, -0Mil NAME PRESENT ADDRESS TEL. # CONTRACTOR:N\IN NAMEWI-rill MAILING ADDRESS TEL.# EMAIL: yU+‘C/; 7U ; 14 sco i (p 9+,A ln,.i • e U rr lit!Residential ❑Commercial 0 Est.Cost of Construction$ '115 tC13 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 A Replacement windows:# Replacement doors: # Roofing: #of Squares r- Insulation Temporary Mobile Home Temporary Construction Trailer • Demolition-Interior only Demolition Raze Structure Solar System ESS System Chimney Fence iieasc submit tttilit3- discountct later; for elccii ie & ka) Ntt uctures ovor ' gears old require hi.)tIrik.al rcv ivS`. *The debris will be disposed of at: D L LSi'1 , ^ L. i ..S\ \A'�m� `. �` ' t 1 a 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 answer(s) will be just cause for denial or revocation of.mv license and for prosecution under M.G.L.Ch.268.Section 1. ^ '�� Applicant's Signature: Y iillig r . Date: IQ1 0W :ar�S�':i Date: ‘O`D`a-1 U Owners Signature(or attach a t) 1„•�rw� Date: Approved By Building Official(or designee) Rev 6 2-) The Commonwealth of Massachusetts rr Department of Industrial Accidents 1; - ► Office of Investigations liEt Lafayette City Center I ` 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): Van C y Co Address: 1-0 Weers (Y4),,c-k �.l) e Vooc rtA o ,Ht... 6 2 69 City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. n I am a general contractor and I 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. U Remodeling ship and have no employees These sub-contractors have 8. n Demolition workingfor me in anycapacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.# r uired.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.E] 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: 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 perjury that the information provided above is true and correct „aril s Date: 10,0/Z Signature: 41: =�.r••• _. 7 / 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 3EICity/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.DOther Phone#: Contact Person: SUBSTANDARD CONDITION LIST ASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION NO CENTER PLAZA )STON,MA 02108.1904 17)723.3800 00)392-6108 le Number. 1718514-7 Date Issued: 09/21/2026 MAILING NAME AND ADDRESS: WILLIAM RAVEIS INSURANCE AGENCY,LLC 7 TRAP FALLS RD SHELTON CT 06484 AMED INSURED AND MAILING ADDRESS: PRODUCER: ANCY CONTERAS WILLIAM RAVEIS INSURANCE AGENCY,LLC 0 WEBBERS PATH 7 TRAP FALLS RD /EST YARMOUTH MA 02673 SHELTON CT 06484 866-603-1191 ocation of Property: 70 WEBBERS PATH,WEST YARMOUTH,MA 02673 ear Sir of Madam: re above property was inspected on or about 06/19/2026. Association has determined that the property fails to meet reasonable underwriting standards.The specific substandard conditions which make your property 'insurable,their location in the property,and the corrective actions which,if taken,will make the property insurable,can be determined by referring to the list of ibstandard conditions below. Trees must be pruned away from home as they are growing on or over home. BRANCHES OVERHANG RIGHT SIDE ROOF Roof covering is in sub-standard condition. LICHEN ON RIGHT SIDE ROOF INSUFFICIENT ACCESS TO THE PROPERTY,NO INTERIOR INSPECTION POSSIBLE SUBSTANDARD CONDITION LIST IIASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION WO CENTER PLAZA IOSTON,MA 02108-1904 317)723-3800 300)392-6108 'ile Number. 1718514-7 Date Issued: 0912112026 MAILING NAME AND ADDRESS: WILLIAM RAVEIS INSURANCE AGENCY,LLC 7 TRAP FALLS RD SHELTON CT 06484 le request that you correct the conditions indicated within thirty(30)days from the date of receipt of this notice. Should the noted conditions be corrected, ease provide evidence of the corrected conditions,such as photographs. These photographs may be submitted via email to mpivainspections@mpiva.com uploaded by your producer through the producer web portal. Submission of completed repairs may avoid the need for reinspection.If you need additional ne to complete the repairs,please contact the Customer Service Department at(617)723-3800 about a possible extension within thirty(30)days of this notice. you fail to complete the repairs or you fa to obtain an extension to complete the repairs within thirty(30)days from the receipt of this notice or if we are unable verify that the property meets reasonable underwriting standards,the Association may decide not to renew your policy. le hope this information will assist in avoiding a non-renewal of your coverage.If you have any questions,please contact your producer or our Customer ervice Department. ou may appeal this action to the Board of Directors of the Massachusetts Property Insurance Underwriting Association,Two Center Plaza,Boston, lassachusetts,02108-1904,within fifteen(15)days of the date of this notice.The decision of the Board of Directors may be further appealed to the ommissioner of Insurance within ten(10)days of the Boards decision. ery Truly Yours, nderwriting Department istribution:Insured,Producer IMASUBCL PRODUCER COPY