HomeMy WebLinkAboutBuilding Permits BackfileWELCOME TO
BRAY - TAYLOR FARM
(s)
TOWN OF YARMOUTH Building Department
(508) 398-2231 e)d.261
PERMIT NO B-08-1289
ISSUE DATE 5/612008- PROPOSED USE
APPLICANT :Bamstable COUMy Shemft's Dept - - - - -
BUILDING
PERMIT
JOB WEATHER CARD
PERMITTO TENT
AT (LOCATION) 10108BRAY FARM RD NORTH ZONING DISTRICT= Bldg. Type: Commercial '
SUBDIVISION MAP LOT BLOCK
LOT SIZE
BUILDING IS TO BE: CONST TYPE I5-BI USE
ERECT TEMPORARY TENT -DURATION 5130/08-612/08
REMARKS
AREA (SO FT) EST COST ($ $0.00 PERMIT FEE ($)
OWNER TOWN OF YARMOUTH BUILDING DEPT BY
ADDRESS 10108 BRAY FARM RD NORTH
YARMOUTH PORT I MA 102675
PHONE
CONTRACTOR
LICENSE 0
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.
ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE APPROVED BY THE JURISDICTION.
STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENT OF PUBLUC WORKS.
THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM INSPECTIONS REQUIRED FOR ALL
APPROVED PLANS MUST BE RETAINED ON
WHERE APPLICABLE
CONSTRUCTION WORK: 1) FOUNDATIONS OR
JOB AND THIS CARD KEPT POSTED UNTIL
SEPARATE PERMITS ARE
REQUIRED FOR ELECTRICAL
FOOTINGS. 2) PRIOR TO COVERING STRUCTURAL
FINAL INSPECTION HAS BEEN MADE.
WHERE A CERTIFICATE OF OCCUPANCY IS
PLUMBING/GAS AND
MEMBERS (READY FOR LATH OR FINISH
REQUIRED, SUCH BUILDING SHALL NOT BE
MECHANICAL INSTALLATIONS.
COVERING) 3) FINAL INSPECTION BEFORE
OCCUPIED UNTIL FINAL INSPECTION HAS
OCCUPANCY 4) REFER TO DETAILED INSPECTION
BEEN MADE.
SCHEDULE
POST THIS CARD
SO
IT IS VISIBLE FROM
STREET
BUILDING INSPECTIONS APPROVALS
1
\ \ ! J
1
2
2 \ \ / �
2
3
OTHER:
1 `
f
1
2
3
4
5
WORK SHALL NOT PROCEED
PERMIT WILL BECOME NULL AND VOID IF
INSPECTIONS INDICATED ON THIS CARD
UNTIL THE INSPECTOR RAS
CONSTRUCTION WORK IS NOT STARTED WITHIN SIX
CAN BE ARRANGED FOR BY TELEPHONE
APPROVED THE VARIOUS
MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED
OR WRITTEN NOTIFICATION.
STAGES OF CONSTRUCTION
ABOVE.
TOWN OF YARMOUTH Building Department BUILDING
(508) 398-2231 ext.261
PERMIT NO B-08-1289_
ISSUE DATE 5/6/2008 _ PROPOSED USE
APPLICANT _Barnstable County Shenift_s_Dept.
PERMIT
JOB WEATHER CARD
PERMITTO TENT
IAT (LOCATION) 0108BRAY FARM RD NORTH ZONING DISTRICT Bldg. Type: Commeroial I
SUBDIVISION MAP LOT BLOCK 1151.24.1 1 BUILDING IS TO BE:
LOT SIZE
ERECT TEMPORARY TENT -DURATION 5/30/08-6/2/08
REMARKS
AREA (SO FT) EST COST ($ I$0.00 PERMIT FEE ($)
OWNER ITOWN OF YARMOUTH BUILDING DEPT BY
ADDRESS 10108 BRAY FARM RD NORTH
YARMOUTH PORT MA 02675
YOUR SPECIAL ATTENTION is called to the following:
USE
PHONE
CONTRACTOR
LICENSE 0
This permit is granted on the express condition that the said construction shall, in all respects, conform to the Ordinances of this
jurisdiction including the Zoning Ordinance, regulating the construction and use of buildings, and may be revoked at any time upon
violation of any provisions of said ordinances.
Weatherproof placard given at the time permit is issued must be displayed on premises. The Department must be ratified and inspection made of prior
construction work as requested on weather card. All new buildings and additions and aherations to existing buildings require a minimum of three called
inspection, namely, 1) Footings, drain tile systems, foundation and basement walls, when walls are at least two feet high, but before back fillings the
wall and before proceeding with the superstructures. 2) Framing prior to lath or finish covering but after firestopping, electrical, plumbing and mechanical
systems are Installed. 3) Final inspection when building or structure is completed.
On jobs involving reinforced concrete work, inspection must be made after steel is in place and before concrete is poured.
The Department reserves the right to reject any work which has been concealed or completed without first having been inspected and approved
by the Department in accordance with the requirements of the various codes.
Any deviation from the approved plans must be authorized by the approval of revised plans subject to the same procedure established for the
examination of the original plans. An additional permit fee is also charged predicated on the extent of the variation from the original plans.
Permits are not valid if construction work is not started within six months from date permit is issued.
Request for Final Inspection should be made by postcard or phone call to this department when the construction work is completed and heating
apparatus has been installed. Painting or decorating is not required before the Final Building Inspection.
Final Inspection and certificate of occupancy must be obtained before occupying buiding.
APPLICANT COPY
a ry TOWN OF YARMOUTH Building Department
BUILDING
- - - - - - - - , (508) 398-2231 ext.261
+�
PERMIT NO B-07.1336- . --- ---
ISSUE DATE ;- PROPOSED USE
PERMIT I
521/2007.,
APPLICANT :chase canopy - - - - - - - - - - - - - - - -'
- -- --- --- --- -- ---- -
JOB WEATHER CARD
PERMITTO ' Miscltent
IAT (LOCATION) 10108BRAY FARM RD NORTH ZONING DISTRIC R<0 Bldg. Type: Commercial I
SUBDIVISION MAP LOT BLOCK 151.24 BUILDINGISTOBE: CONSTTYPE= USEGROUP=
LOT SIZE
erect temporary tent - duration: 6/2107 - 6/4/07
REMARKS
AREA (SO FT)
OWNER L'
ADDRESS F1
OFYARMOUTH
rote 28
EST COST ($
BUILDING DEPT BY
CONTRACTOR
LICENSE 0
P.O. Box 46
Mattapoisett MA 02739
5087582055
PHONE 15083982231
INSPECTION RECORD FIELD COPY
EXPRESS BUILDING PERMIT
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261
CONSTRUCTION ADDRESS: /08
Fee f "'�--
Pemtit expire 6 mrnW 6nm
t aeon date.
L 'u' L5
MAY 1 8 2007
ASSESSOR'S INFORMATION:
/' Map: !.S/ Parcel:
OWNER: /JL.-ail o yCL It"- YN
NAME PRESENT ADDRESS TEL x
DULD:NG GZPT
❑ Residential ❑ Commercial Est Cost of Construction f
Home Improvematt Contractor Lic. # Construction Supervisor Lic. #
Workroom's Compensation Insurance: (check one)
❑ 1 am the homeowner 0 I am the sole proprietor ❑ 1 have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp. Policy#
WORK TO BE PERFORMED
great (Fhe Retardant CertiOcaea 6 2 - Woad strove POLDKING
PROVED
❑ siding: x of Squams ❑ Replao:mect windows:
C Replacement dowse # 182007
t
a Re f.. # of Square
() Stripping old shingle' ()going ova layers of existing roofM OUTH
'S HIGHWAY
•The debris will be disposed of at
Location of Facility
1 declare under peneRies of perjury that the stammeab hernia contained are hue and correct to the best of my knowledge and belief. I understand that arty false answer(s)
will be just came for denial or rcvocabo��n Of my license
cand
�^lot prosecution under MO.L Ch. 269, Section 1. AA
Applicard's Signaoue: � 'u' Y`� C�lICL4�- DatF `>"- l7- 67
Owners Signature (er enachmcot) pate:
Approved By: Date:
Building Official (or dwigoee)
Zoning District: RI/0 _
Historical District: A Yes ❑ No Flood Plain Zone: Yes ❑ No
Water Resource Protection District: Within 100 R of Wetlands:
❑ Yes J�No �-,Yes ❑ No
3101
Department of Industrial Aeefdents
OVIce of Investigations
600 Washington Street
Boston, MA 02111
www.araugouldle
Workers' Compensation Insurance Affidavit: Builders/Contradora/Electrldana/Plumbers
Are you an employer? Check the appropriate box
1. 111 am a employer with 4. ❑ 1 am a general contractor and I Type of project (required)-
employees (9rn and/or part-time).* have bhW the cob-mntrac6ora 6• ❑ New constrwinn
2. ❑ 1 am a sole proprietor or parmer. listed on the attached sbeot t 7. 0 Remodeling
ship and have m employees These sub-controcron have S. Demolition
worl®g for me in any capacity. workers' camp. insornium 9. ❑ Building addition
[No workers' comp. insurance S. ❑ We are a corporation nod its .
requited.] ot6cers have exercised their 10.El Electrical repairs or additions
3. ❑ I am a homeowner doing all work right ofexemptioa per MGL 11.❑ Plumbiag repairs or additions
myself [NO workers' comp. C. 152, ¢101 and we have no 12.❑ Roof repairs
insurance required.) t employees • (No wodcua' 13.❑ Other
comp. insurance re9�1
wa -Jr � oo a are eecma oenw arowma mtr wofftw coaymnaoo Deft
t Homaor vAo oEmaffis affidavit They ern doing an oak and rhea hka Oft" coabacton mot subioaft a cow alsdava lodcwrina sack
tConhalms mar daokthis box rant aarhad as additimW ahnt shoving on ofmanb•mohaRra and mdv waken' clog, policy iofrnflon.
I has a enrployotAaf It provldlna rrorAera' eonrpeaaatfon lesunwei jo►aq enrp/oyeea Bdow it the polig onstjob sise
btferraaakn.
Insurance Company Name:
Policy # or Self -ins. Lic. # Expiration Date:
Job Site Address: City/Statecip:
Attach a copy of the workers' compensation policy declaration page (ghowring the policy number and expiration date).
Fanure to stare 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 wen as civil penalties in the farm of a STOP WORK ORDER and a fine
of cop m $250A0 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Invesdgatim of the DIA for iavmance average verification.
I do Aenby cerdfy under the paint and penalties ofperjwy drag the /njormaaon prodded above b line surd correct
Signature: D
O.B7dd ase onhs Do nor -write /n tkh any to be compkted by clry, or town of/kld
City or Town: PermWl sense
Issuing Authority (drde one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone
HFh 3Q ?CO-' H;1F! 04 d3 ,,slrl ..
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LIABILITY INSURANCE
AcOR -
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ONLY ANDr.CNI-ERS AIO FIGH75'.'PC%, THE CERTIFICAIL
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P.O. Box 63310
Ilnd"e, CA 926193310
Chew Canopy Co,mpuny. '_LC
4Nlcky'bLane
Mattepolsett, MA 02719
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4bn1 ili collerayu.
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IMPORTANT DOCUMENT
(Urtif mate
REGISTERED
APPLICATION a
NUMBER
F140.1
of f lame
ISSUED BY
x CNOR.
EVANSVILLE, INDIANA 47711
Re.i6tance
MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have
(or are inherently noninflammable) and were supplied to:
266675
CHASE CANOPY COMPANY
4 NICKY S LANE
P O BOX 46
MATTAPOISETTE MA027390406
Date of Manufacture
02/03/00
Order Number
310460
been flame-retardant treated
Tc yoxavM - I
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, equal to exceeds NFPA 701, CPA[ 84, ULC 109.
The method of the FR chemical application is:
Serial #:
8140100(2)
Description of item certified:
CENT MID 40W X 20 VL W W
Flame Retardant Process Used Will
Washing And Is Effective For The
Signame of App icator o lame esistan[ Finisb
Not Be Removed By
Life Of The Fabric
1 � g",_Q
DEPARTMENT —ANCHOR INDUSTRIES INC.
IMPORTANT DOCUMENT
(Cierfif it to
REGISTERED
APPLICATION y
NUMBER JL
F140.1 �
Of f lar t
ISSUED BY
yea INC.
EVANSVILLE, INDIANA 47711
Rvgfigtanre
MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have
(or are inherently noninflammable) and were supplied to:
266675
CHASE CANOPY COMPANY
4 NICKY S LANE
P0BOX 46
MATTAPOISETTE MA 02739D406
Date of Manufacture
02/03100
Order Number
310460
beets flame-retardant treated
7cYOX,9046-7.;-
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, equal to exceeds NFPA 701, CPAI 84, ULC 109.
The method of the FR chemical aoolication is:
Serial C
8140300(1)
Description of item certified:
CENT END 40W X 201A VL W W
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The ALife Of The Fabric
Signed: -'Z2 g'f `
Name of Applicator of Flame Resistant Finish /I/ TENT DEPARTMENT —ANCHOR INDUS
REGISTERED
APPLICATION
NUMBER
F140.1
IMPORTANT DOCUMENT
of flame
ISSUED BY
IIg1OR.
W INDUSmIE6
EVANSVILLE, INDIANA 47711
Re'5I5tance
V MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have
(or are inherently noninflammable) and were supplied to:
266675
CHASE CANOPY COMPANY
4 NICKY'S LANE
P O BOX 46
MATTAPOISETTE MA 027390406
Date of Marwlacture
02MM
ONer Number
310460
been flame-retardant treated
'Tc y&7X-2 —I? y
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, equal to exceeds NFPA 701, CPAI 84, ULC 109.
The method of the FR chemical aoolication is!
Serial #:
0140200 (1)
Description Of item certified:
CENT END 40W X 20 HO VL W W
ra111W nvLafuatu rrvUess Usea Mill Not tie Removed By
Washing And Is Effective For The Life Of The Fabric
Name of APP11cat0r of Flame Resistant Finish
INC.
TOWN OFYARMOUTH
Building Department
BUILDING
+
_
(508) 398-2231 ext.261
PERMIT NO B-07-1179
PERMIT `
= =
ISSUE DATE - 4/13/2007 - ;
PROPOSED USE
----
APPLICANT Taylor -Bray Farm
- -- ------'
JOB WEATHER CARD
PERMIT TO Misci-tem
AT (LOCATION)
ZONING DISTRICT�
Bldg. Type: Resitlemial
10108BRAY FARM RD NORTH
SUBDIVISION MAP LOT BLOCK 151.24
BUILDING IS T B STTYPE= USE GROUP=
LOT SIZE
��
CONTRACTOR
temporary tent - duration: 7/27/07 - 7129/07
REMARKS
AREA (SO FT) EST COST I$ $0 i
OWNER ITOWN OF YARMOUTH
ADDRESS 108 Bray Farm Road North
Yarmouth Port I MA 102675
PERMIT FEE ($) $O.W
BUILDING DEPT BY
LICENSE 0
PHONE 15083989407
INSPECTION RECORD FIELD COPY
5 O�..ygR'ri
RECEI`s:=D
APR 1 3 2007
EXPRESS BUILDING PE . 'I'-Arl
TOWN OrY �fUIJ1n
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261
CONSTRUCTION ADDRESS:
ASSESSOR'S INFORMATION:
Map:
f
OWNER
i
CONTRACTOR
'n-Residential ❑ Commercial
Parcel:
ESL Cost of Construction
Home Improvement Contactor Lic. #
Constmcncm Supervisor
Workmen's Compensation Insurance: (check one)
❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance
Worker's Comp. Policy#_
Insurance Company Name:
WORK OBE PE RMED
Trnt (Fire Retardant Certificate attar � �j � q � WoodStove
Dmffioo / /��
❑ Replacement windows,
❑Siding #of Squares C Replacement loon: #
0 Re -roof. # of Squares • layers of exislinB ronf ---- I
() Strippin6 old shingles () going /
'The debris will be disposed ofat: r aim of Facility
Limue
--� //7
�,
pin s 6 montlu from
.
RECEI
APR 13 2007
HIGHWAY
I declare under penalties of perjury that the statemeu herdn couraiued are tme and cortex to the best of my knowledge and belicE I understand that any false answer(s)
will be just cause for denial a &O-hm of my li rn Tor prosecution tmda M.G.L Ch. 268. Section 1.
Date .3
Applicant'sSignature.
J v
Owners Signature (or amcbmem) •�� �: Y /
Dac
Approved By. Building Official (a designee)
Zoning Distict:_
FHistoricalrictNo
: Yes ❑ No Flood Plain Zone: y� x es ❑ No
e Protecti n District: WithJin ,too R ofWellnd ::s 077zr /"--yCs
3/01
.40-A Department ojlndust id Accidents
.9 Of ee of Investiradons
lip 600 Washington Shea
Boston, MA 02111
tvwMmasaaovIdle
Worllerar Compensation Insurance AMdavit: BlilderslContractors/Elep ders
dan&Tlum
A &ant information
Name
Address:
City/StattlZip:
Phone #:
Are you as employal Cheek the appropriate box:
Type of project (required).
1. ❑ 1 am a employee with
4. ❑ I am a general contz clor and I
6. ❑ New conrtrnetion
employees (rA and/or pm tbn4f have Lard the sub-mnhacbn
listed on the attached shect t
7. ❑ Remodeling
2. ❑ I am a role proprietor at parmeo-
ship and have no employed
These sub-contracbn have
8. ❑ Demotido t
[N �for me in any
m mny. '
wod=s* comp. h:emane6
s. ❑ We ate a wlporation mod its
9. addition
lo.❑ Electrical lepana or additions
3. ❑ I requab
abomwwner doing an walk
otlieen haw exercised their
right of exemption per MOL
1I.Plumbing repairs or additions
❑
myself (No wtslcen, comp-
c.152, 41(4)6 and we have no
12.13Roof repair
insurance tequked ] temployom
mmm� �I
13.0 Othee
•Any wpplicre mnebedabn alter eha all Get00 &wide below rbawbq dwiewabd ee&4rMarP0ft bftUMdat
t Homrwmwbe obmitadaemJevit loadtha any we debt an workeodmetbdn Oct" MUIFU nteraubma■dewamdavh lodicrbaa rch
t[�am.etaor ter eLeekmYtm and eaerad r tlatloeal duel �howlea m. cow otme febaobw,tor ed metr wo,kad coop poiiry lolbrnrtirl
Ilse O eatp ojfr fh&f is ptwldlad:NOlAfrs� coatpsnaldois la7Y//aef fM aq satplayffa Below to de piney and fob all#
rnforma*m
Insurance Company Name
Policy 0 or Self -ins. Lie.
Expiration Date.
Job Site Addraa city/S°M74`
Attach a copy of the workers, compensation policy declaration page (showing the policy number and expiration date}
Failum to seam coverage w required coda Section 25A of MGL c. 152 an lead to the imposition oferiminal penalties of a
time up to $1,500.00 and/or one-year imprisoumen% see well as civn penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violaur. Be advised But a Copy ofthis statement may be forwarded to the Office of
Ins estigations of the DIA for im u=m coverage vailtadon.
I AP hereby eerd# ender the pains end penables ojperjuy t/tat the Injorradon prodded &bow As bee dad comets
0,p1d ass onfjr Do oar wrfte in tAh one, to be completed by ciq, or amw odWA
City or Town:
Pern ltlucense 0
Issuing Authority (circle neeP
1. Board of Heakh L Banding Department J. City/Town Clerk 4. Meetried Inspector 5. Plumbing Inspector
6. Other
Contact
APR. 10. 2007 2 43VA
NO. 169 P
COMM IDNW:nLTH Oar MIASSACHUSETTS
BARNSTABLB COUNTY CORRECTIONS FACILITY
U96000 Sheriff s Place r
Houme, v A b2531
Phane;503-563-4300
-Fat}5CS-563.4574
BCSO@bsheriff.net
Sheriff Jarnes M. CuXn=ings
RU rH w
To; Y_
From:
Subject:
Date:
Integrity,PTC&SionahSru
Compassion & Teamwork
Facsimile Cover Letter
,D�r- NaI Z-
17
Total Number Of Pages including cover letter: 0—
FAX COVER SHEET WAKN 0
THI: INFORMATION CONTALNED IN THIS FAX NE, SSAGE IS INTENDED ONLY FOR TIM PERSONAL AND CONFLOEN•
TIAL USE OF THE RECIPIENTS NAMED ABOVE.THIS MESSAGE MAYBE A COMMUNICATION WHICH -AS SUCH,IS
PRIVILEGED AND CONFIDENTLAL,IF THE ROADER OF THIS MESSAGE IS NOT THE INTENDED RECIPEENT ORAN
AGENT RESPONSIBLE FOR DELIVERING IT TO THE INTENDED RECIPIENTS,Y CU ARE IMUBY NOTIFIED THAT YOU
HM T RECEIVED THE DOCUMENT IN ERROE AND THAT ANY REVIEW, DISSEVIINATION, OR COPYING OF THIS MES-
SAGE IS STRICTLY PROHIBITED-7 YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY US
IMN EDIA_ ELY BY PHONE AND RETURN THE ORIGINAL TO US BY MAIL.THANK YOU-
BARNSTA13LE-BOURNE-BREWSTER-CHATHANI-DENNIS-EASTHAM-FALMOUTH-HARWICH
MASHPBE. ORLEANS-PROVINCETOWN-SAND WICH-TRURO-WaLFLEET•YARMOUTH
APR. 1C. 2U7 2 550 ua t7t O. 772 3 P. 1
NRY. 4, 1.406 10'.1bM D�6r af] an awcweYrLLma,� ^•
- IMPO.RTANT DOCUM
certificate of Flame zesistaWe
ISSUED BY E
Shiamera
"'GTRA IO N pp a UC6N4
1CATlON iww�-AA
uUUp CR on1EVANBVILL¢, INDIANA 47r2501YM
P13I 1 MANUFACTURERS OF THE FWSHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardand treated
(or are Inherently noninflammable) and were supplied to:
78980
BARNSTABLE COUNTY CORRECTIONAL
9000 SHERIFF'S PLACE
BOURNE MA02532
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 dens In conformance with California
Fire Marshal Code, All fabric has been tested and passes NFPA 701.99r CPA) 84, ULC 109.
Sena) N 1000100111
of Item ceruaed:
n9E7ATCP 08WM WH1t8'iWL
arne Retardant process Used Will Not fie Hemoveo c
Washing And Is Effective For Thelife Of ' be Fabric
„� ..esa_crr_en0_r.a dd0a5 eLErt1 so 40 ROW
TOWN OFYARMOUTH Building Department BUILDING
+ (508) 398-2231 ext.261
PERMIT NO B-07-1093_ PERMIT
.ti ems. ISSUE DATE 3/30/2007 _ PROPOSED USE _ _
APPLICANT Robert Carlson
___ __ ________ JOB WEATHER CARD
PERMITTO AccessorYstwmum
AT (LOCATION) 1108BRAY FARM RD NORTH ZONING DISTRIC R-40 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 151.24 BUILDING IS TO BE: CONST TYPE USE GROUP
LOT SIZE
construct 12 x 16 sheep shed as per plans dated 03/29/07
REMARKS
AREA (SO FT) EST COST ($ $1,000.00 PERMIT FEE ($)
OWNER ITOWN OF YARMOUTH BUILDING DEPT BY
ADDRESS 1146 Route 28
INSPECTION RECORD
CONTRACTOR
LICENSE 083857
Carson, Robert
1146 Route 28
South Yarmouth MA 02664
5082942416
PHONE 5083982231
FIELD COPY
LVA
oF'Ak� ONE & TWO FAMILY ONLY - BUILDING PERMIT
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Town of Yarmouth Building Department
F 3y 1146 Route 28 • Yarmouth, MA 02664-4492
Tel: (508) 398-2231 x261 • Fax: (508) 398-0836 RECEIVED
Office Use Only
Board Information
Assessors DepartmeAInformatio MAR 2 3 2007
2
No. (6 6 ate✓
er,Pllanning
E ,PT Tvve
LaPermit
_aE orsement Date
ILDING CENT.Permit
Fee $
Recording Date
By —
Deposit Rec'd. $ ate _
Plan No.
1.4 Property Dimensions:
Net Due $
Other
LotArea(sf) Frontage(ft) Lot Coverage
This Section for Office Use On
BuildingPermit Number
Date Issued:
Certificate of Occupancy
Signature:
is is not required
Building official Date
Section 1 - Site Information Use Group: R-4
1.1 Property Address:
/06 a,"'y�m ,�,) 1/Wm"WRat
1.2 Zoning Information:
k�
Zoning District Proposed Use
fit)
1.3 BuildjFrom
Side Yards
Rear Yard
ReqProvided
Required
Provided
Required
Provided
1.4 WateL. c. 40. S 54)
1.5 Flood Zone Information: Comments:
Publiate
Zone: BFE:
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Record:
'/own elruwu_fA
Name print) Mailing Address
FtI
awn
Signature Telephone Fax E-mail
2.2 Authorized Agent:
(Ion l�Z/I re /03 15 2g Frenkf .6; o Ccrf
Nam (print) Mailin Address
00-39S- 407 44elil d Ifn
Sig re elep&np 170
1
Section 3 - Construction Services
3.1aicensedfonstruction Super,Asor:
D�a
L..s 5 3e. - -7
�,.y �J ,�
3 9 v ry� �� W' �✓ h�
Address i MW
Expiration Date
-�
Si r Telephone Q y2 Y/&' E-mail
Section 4 - Workers' Compensation Insurance Afffrfevif me r- t .. i cn a ncr
-------- .-,.... --- - .--- --- '-"
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes .......... No ..........
Section 5 - Descri tion of Proposed Work (check all applicable)
New Construction No. of Bedrooms No. of Bathrooms
Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. Type
Demolition
Other Specify:
Brief Description of Proposed Work:
don6-hyC !Z' JX !G ' r5hee 6hed
Section 6 - Estimated Construction
Costs
Item
Estimated Cost (Dollars) to be
completed by permit applicant
Check Below
❑ Conservation -Commission Filing
(if applicable)
Old Kings Highway & Historical
Commission approval
(if applicable)
1. Building
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5)
7 Total Square Ft. (new houses &additions)
Section 7a - Owner Authorization -
Owner's Agent orContractorAp lies
To be Completed When
for Building Permit
1, , as owner of the subject property
hereby authorize to
act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
Section 7b - Ow ne Authorized Age Declaration
1, hb ri I 4zl re— , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
7cn M�Tn�re
Print name //
� J"YAn
Signature of Owner/Agent Date
9-15-99 2 of 2
TOWN OF
YARMOUTH
a�c
�.•:.•••„ S
BUILDING DEPARTMENT
CONSTRUCTION
SUPERVISOR
FORM
PLEASE PRINT)
L
n
Aq, n 4
/ P6
Job Location:
N,,.hrr Street
I , I
Village
Owner of Property: LV /' - t
Construction Supervisor:
Name License No. Phone No.
Address:
Licensed Designee:
(If other than Supervisor)
Name
% ^ 4a /-XA 6
License No.
2.15 Responsibility of each license holder:
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall will£ullyviolate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE.
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes ❑ No ❑
If you have checked M, please indicate the type coverage by checking the appropriate box.
Bond ❑
A liability insurance policy ❑
Other type of indemnity ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
of Owner or
Owner I] Agent
Signature: Building Official Approval:
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work: ICJ<7an Est. Cost
Address of Work 168'
Owner Name:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_ Work excluded by law
Job under $1,000
Building not owner occupied
_ Owner pulling own pennit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury•
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property,
Date Owner Name
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, bfA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Orgmiration/Individual):
r;tv/Rtnte/7in:
Phone #•
Are you an employer? Check the appropriate box:
4. ❑ 1 am a general contractor and I
1. ❑ I am a employer with
employees (full and/or part-time).'
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
These sub -contractors have
ship and have no employees
employees and have workers'
working for me in any capacity.
comp. insumRCe.t
workers' comp. insurance
5. ❑ We are a corporation and its
required.]
requued.]
3. ❑ I a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself workers' comp.
insurancee required-] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7 ❑ Remodeling
g. ❑ Demolition
9. ❑ Building addition
ME] Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
'Any applicant that checks box #1 must also fill out the section below showing their workers comPrnsation Policy infomation.
t Homeowners who submit this affidavit indicating they an doing all work and then hire outside contractors must submit a new atTdavit indicating such.
,Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees, they must provide their workers' camp. policy number.
I am an employer that is providing workers' compensation insurancefor 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 e. 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 forwaztied to the Ofizce of
Investigations of the DIA for insurance coves a verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
nate
use
City or Town:
to be completed by city or town official,
Permit/License #_
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
0
PLEASE PRINT
DATE:
JOB LOCATION:
"HOMEOWNER"
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 260
HOMEOWNER LICENSE EXEMPTION
NAME STREET ADDRESS SECTION OF TOWN
NAME
PRESENT MAILING ADDRESS
HOMEPHONE WORK PHONE
CITY OR TOWN STATE ZIP CODE
The current exemption for `Homeowner' was extended to include owner — occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that such
homeowner shall act as supervisor. (State Building Code Section 108.3.5.1)
Definition of Homeowner.
Person(s) who owns a parcel of land on which he / she resides or intends to reside, on which there is or is intended
to be, a one or two family attached or detached structure assessory to such use and / or farm structures. A person
who constructs more than one home in a two-year period shall not be considered a homeowner; such "homeowner"
shall submit to the building official, on a form acceptable to the !wilding official, that he / she shall be responsible for
all such work performed under the building permit. (Section 108.3.5.1)
The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142.
Yes ❑ No ❑
If you have checked }_es, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
hfiomeownrlicexemp
If
TOWN OF YARMOUTH
1146ROUTE28 SOUTHYARMOUTH IvIASSACHUSETl'S02664-4451
Telephone (508) 398-2231, Ext. 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at �� Of3 �oa� rd-� a
Work Address
is to be disposed of at the following location: cc�f7 �I
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Allplicant Date
Permit No.
Old King's Highway Regional Historic District Committee
in the Town of Yarmouth for a
APPLICATION FOR
CERTIFICATE OF APPROPRIATENESS
Application is hereby made in triplicate, for the issuance of a Certificate of Appropriateness, under Section 6
of Chapter 470, Acts and Resolves of Massachusetts,1973, for proposed work as described below and on
plans, drawings or photographs accompanying this application for:
CHECK CATEGORIES THAT APPLY:
11
1. Exterior Building Construction: G NEW Building ❑ Addition ❑ Alteration
Indicate type of building: C House C Garage ❑ Commercial GOther
2. Exterior Painting: ❑
3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting existing sign ^ �'
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other
C co`70
TYPE OR PRINT LEGIBLY DATE %b • tri
ADDRESS OF PROPOSED WORK 100 raJraN rC(,I A,I Kam[ . /iiy,ASSESSORS MAP
t
OWNER /own v-,if ASSESSORSLOTNO. 29,
HOME ADDRESS TELEPHONE NO.
GENT R CONTRACTOR �rt c -Z/7 �e TELEP//H--ONE N0600 -,38s —`J407
ADDRESS /03 y gra/Jo L%�1Ut✓`KlnnrTGIPCODE 026-2
USE ATTACHED SHEET (PAGE #3) IN PACKET FOR ABUTTING OWNERS
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done including materials to be
used in case ofsigns, give locations ofexishng signs and proposed locations of new sism. (Attach additional sheet, if necessary).
r3u91cf 5l1eeF Jh&-d U5101 Z'X-4' do✓I.s;4r cfron,
rem Gec%t roo-
t
, cu%1,-fe Ce-dar fsll tnA les on S lcfsv �e2(ls.
4` 'a 61,Y"Date t b.IzI2oa7
Owner-Contracto Agent is aware t at a Permit is required from rtmen
All new construction will be subject to inspection by OKH Inspect 0 V E D
It is required that OKH approved (with BD stamp) plans are avai a on site for t e
and final Inspections. MAR 072Z7 t
Date This Certificate is hereby
Check Dat /
By.
APPROVED IMPORTANT: If Certificate is approved, approval is subject to the 10 day appeal
period provided in the Act
DISAPPROVED ❑ PLEASE RETURN TO: Yarmouth OKHC District Committee
Yarmouth Toxin Hall, 1146 Route 28, S. Yarmouth, MA 02664
7Aai9
SPECIFICATION SHEET (YARMOUTH OKHC)
• Provide color chips and attach where necessary.
• New House: Provide landscape Plan. On Site Plan show exterior lighting and elearric meter
Description of proposed
FOUNDATION (18" MAX. EXPOSED): CONCRETFIOTH�R DRIVEWAY:
Goner-rf� sl�-6
WALKWAY: STEPS (INDICATE BRICK/CEMENT/OTHER):
SIDING TYPE & MATERIAL: &A,4c cedar -6A n R /es
CHIMNEY (INDICATE BRICK/STUCCO/WOODFACED)
ROOF MATERIAL: PITCH (7 .)- MAX. EXP. 6 ` -
ff��cN'
WINDOWS (GRILLES REQUIRED�THER)
INDICATE SIZES IF NOT LISTED ON EL VATIONS:
DOORS 00 S OTHER)
(INDICATESIZES AND STYLE IF NOT LISTED ON ELEVATIONS):
TRIM: (ALL WINDOWS & DOORS TRA4MED WITH IX4 ,�
MATERIAL OF TRIM: (WOOD ALUMINUM)
SHUTTERS (WOODNINYL) (PANELED/LOUVERED)
GUTTERS (WOOD/ALUMINUM:
GARAGE DOORS: SIZE & STYLE:
STORM WINDOWS & DOORS:
(INDICATE SIZES IF NOT LISTED ON ELVATIONS)
SKYLIGHTS: TYPE/SIZE: - _ - -
WOOD DECK: SIZE:
WOOD FENCING (MAX. HEIGHT 6): STYLE:
(SHOW LAYOUT & RUNNING FOOTAGE ON S17 PLAN)
RETAINING WALL: (P.T. OR FIELDSTONE -CONCRETE
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
SIGNS: (indicate size, style, colors)
SIGN POST: (indicate size, style, color)
Additional Information
COLOR:
COLOR:
COLOR
COLOR:
COLOR
COLOR:
COLOR:
COLOR:
COLOR
COLOR:
COLOR:
COLOR:
COLOR:
,
1
/
i
i
i
Pasture
ex i si- T7q
Chicken
�C cop ¢Pe-n %
kc
Gam,. Prop
ee���/e �rst •�„� " _
IV
/K// � •ter
1 /
/ r
r' l/ Pas+vre
ICI
u.'
I
PPROVED
' �M MAR 081007
),
/ ) / YARMOU TN
D KING HIGHWAY
__
l/ P/Ot Flan
J`.yOI,cJN7q PfOPO`�d eheeD shed
at'
7 ulor- Ora y Farm
y&rmoufti Por,
7A�i9
a
xj
Za
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No
o
00
=C
ti
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.y TOWN OF YARMOUTH
®tg Building Department
= Town Hall
.. Yarmouth, MA 02664
(508) 398-2231 ext.261
BBUILDING PERMIT
TRANSMITTAL
Temp Permit No.:
T-07-404
Applicant Name:
Robert Carlson
Applicant Phone:
5082942416
Building Location:
0108 BRAY FARM RD NORTH
Owner's Name:
TOWN OF YARMOUTH
Owner's Addres
1146 Route 28
South Yarmouth MA 02664
r
Owner's Telephone:
(508)398-2231
(OFFICE USE ONLY
Recorded By:
Ic
Permit Fee:
$0.00
Deposit Rec:
$0.00
Payment Type:
Check ChkNo.. 0
Net Owed:
$0.00
Application Date:
3/23/2007
Issue Date:
Expiration Date
Comments: Map
construct 12 x 16 sheep shed
On DATE: N/A:
/�.�� ENT DATE: N/A:
t DATE: N/A:
DATE: N/A:
5. BUILDING DEPARTMENT DATE: N/A:
6. FIRE DEPARTMENT DATE: N/A:
PLEASE NOTE
COMMENTS:
RECEIPT OF COPY- SIGNATURE OF APPLICANT
DATE:
151.24
Date Printed: 3/27/2007
Old King,$ Highway Regional Historic District Committee
In the Town of Yarmouth for a
CERTIFICATE OF APPROPRIATENESS
T*2
Application is hereby made is triplicate, for the Issuance of a Certificate of Appropriateness, under
Sating 6 of Chapter 470, Acts andResolvesOf Massachusetts, 1 �+ for proposed work as described
below and on plans, drawings or photographs P accompanying PP
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction: ❑ New Building ❑ Addition ❑ Attention
Indkets type of boning ❑ 9oan ❑ GanP ❑ Cosserdal ❑Othw 1
_ N
2. Exterior Painting: ❑ 1 i
D. Sigma or Billboards: ❑ New Sip ❑ Exletlng Sip ❑ Repaludag exiadog alp
4. Seracturr. ❑ Peen U Wali ❑ Flagpole ❑ Other � :J
O
DATE
�g nv vvf>,ta I_F.GIBLY f
ADDRESS OF PROPOSED WORK /08 Fi2WFc�t Lc— tC Co ASSESSORS MAP N0. / S/
-- _ _L9 " — ,a, ASSESSORS LOT NO.
HOME ADDRESS TELEPHONE NO.
7N
AGENT OR CONTRACTOR 7'R F PA TELEPHONE NO SOB
P�r4 MA ZIPCODE !2 75'
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERST
DETAILED DESCRIPTION OF PROPOSED WORK Give alt pmHculora of rmk to be done lwluda:g materiais to
be used /n can ofsignx Stm /oeatlom of""11-9 signs and proposediocationr of tier sigro. (Attach additional "AVED i
nerM)• YARMOUTH COMMITTEE
(l4.t'.iLe vll Code OKHRD
_ �1
I _ 411
REUlvcd by OKHC
Date Thi+Certificateis 1( _, Date
By�
��
By�
APPROVED ❑ IMPORTANT: If Certificate is approved, approval is subject to the 10 day opal
period provided in the Act
DISAPPROVED ❑ PLEASE RETURN TO: Yarmouth OKHC District Committee
Yarmouth Town Hall, 1146 Route 28, S. Yarmouth, MA 02664
l
SPECIFICATION SHEET (YARMOUTH OKHC)
• Please fill out the form in its entirety and make 2 copies for a total of 3
• Providing color chips where necessary and attach to all 3 copies
• On Site Plan for New House: Indicate landscaping, exterior lighting and electric meter
ADDRESS: / 0 8 3 rp-q F4 wA Rj _ ,t. 6 t �G /1+�� ro '-'-
FOUNDATION (18" MAX. EXPOSED): CONCRETE/OTHER DRIVEWAY:
WALKWAY: STEPS (INDICATE BRICK/CEMENT/OTHER):
SIDING TYPE & MATERIAL. &.)A i f& C e- & r 6111 o g ) e S COLOR: ll z 7 r aJ
CHIMNEY (INDICATE BRICK/STUCCO/WOODFACED) COLOR: ff
ROOF MATERIAL: PITCH (7/12 MIN.) re-d C r d czr 6f t t ! /e s COLOR: /tG.Y-� r�
MAX. EXP
WINDOWS (GRILLES REQUIRED) (WOOD/OTHER)
(INDICATE SIZES IF NOT LISTED ON ELEVATIONS):
(3) Z6" >C Z4'
DOORS (WOOD/OTHER)
(INDICATE SIZES AND STYLE IF NOT LISTED ON ELEVATIONS): COLOR: C r�
3-0 k &- G
TRIM: (ALL WINDOWS & DOORS TRIMMED WITH IX4 / 1X5) COLOR: Co (ori
MATERIAL OF TRIM: (WOOD, VINYL, ALUMINUM) C �O 0 cr
SHUTTERS (WOODNINYL) (PANELED/LOUVERED)
COLOR:
GUTTERS (WOOD/ALUMINUM):
COLOR:
GARAGE DOORS: SIZE & STYLE:
COLOR:
STORM WINDOWS & DOORS:
COLOR:
(INDICATE SIZES IF NOT LISTED ON ELVATIONS)
SKYLIGHTS: TYPE/SIZE:
COLOR:
Y"
WOOD DECK: SIZE:
COLOR: ;
WOOD FENCING (MAX. HEIGHT 6): STYLE:
COLORa
-
>
-D
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
v
o
-<
)0
RETAINING WALL. (P.T. OR FIELDSTONE - CONCRETE INAPPROPRIATE) I I I
C
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
oN
co
n
SIGNS: (indicate size, style, colors)
COLOR:
SIGN POST. (indicate size, style, color)
1
�.M.,.u-a�.1,1:�...uw�T'rv:•nSay..Cal Rk:�:ilwl• 'l�
T
5'6"
LEFT
i�I T I
I �
I1111�1 illfl l� Ali i-
2/GHT
ITI
N
M_
7\
O
& Itt)
SCALE ; �I4"= 1
CH/CKEN COOP
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I-
I a
r'1 0
-- 7 O
FP—O /J-T Rl N _
0 0 17�
co
i-
I
I I,I�,I,t � 5•
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ch.cken
coop
w
exi--41n9
cb/cken
pin
ln'0/ chrok e�n9 pen
pasture
/
i T1
0 -�
CD
a
show/�iProP05ed chicken coop
OY;FIYU t
at
Taylor-Eral Far,
y/armouf b Port
/parch z7, 200(. 5ca/e: l" - 50'
06) tJ
a a Old Kingrs Highway Regional Historic District Committee
in the Town of Yarmouth for a®� �G
CERTIFICATE OF APPROPRIATENESS
Application b hereby made is triplicate, for the issuance of a Certificate of Appropriateness, under
Section 6 of Chapter 470, Acb and Resolves of Massachusetts,1973, for proposed work as described
below and on plans, drawings or photographs accompanying this application for.
CHECK CATEGORIES THAT APPLY:
1. E:prior Building Couatructim: C New Balidlaa ❑ Additlea ❑ Aherallon 1
Indicate type of building: ❑ House ❑ Garage ❑ Commercial ❑Other OA t C ke rl
3. Exterior Painting: ❑
3. Signs or Billboards: ❑ New Sip ❑ 11WIag Sip ❑ Repsiatiog elbtiag 11gn
_ � U O
i
I. Stractore: ❑ panel ❑ Wall ❑ Flagpole ❑ Other " " _? � c::
1 N J_
TYPE ORP yffrEGIBLY DATE Z'Er?i�0'�'
ADDRESS OF PROPOSED WORK /O8 Brk�FAaiti1/E'd. /jo.ASSESSORSMAPNO. /S/
LOT NO. 2"9. /
HOMEADDRESS TELEPHONE
AGENT OR CONTRACTOR 7 R F PA TELEPHONE NO S08 - 3BS- `J'46 rJ
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERS
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be dam iwIudNz materials to
6r and /n ease ofsfgro, give location, of edinUg sign, and pmpared locatioru of new sign. (AttdIch additional "AVED
necewuyl : YARMOUTH COMMITTEE
cle" CR°I° i OKHRD
n vcu vy UNl
Dap This Certificate is e T 1j Date
�
CheckCheck�
By
APPROVED ❑ IMPORTANT: ViCertificate.is ed peppmvv approval is subject to the to day appeal
DISAPPROVED ❑ PLEASE RETURN TO: Yarmouth Town Halt 1146 Route Z8
mo. S. Yarmouth, MA 02664
SPECIFICATION SHEET (YARMOUTH OKHC)
• Please fill out the form in its entirety and make 2 copies for a total of 3
• Providing color chips where necessary and attach to all 3 copies
• On Site Plan for New House: Indicate landscaping, exterior lighting and electric meter
ADDRESS: iU& J'rt �(;wt ��!� •/ y k llytGzJ f�irt
—L
FOUNDATION (18" MAX. EXPOSED): CONCRETE/OTHER DRIVEWAY:
WALKWAY. STEPS (INDICATE BRICK/CEMENT/OTHER):
SIDING TYPE & MATERIAL. tdh i fr: C e-z(a-r nf1 r It 1 f e s COLOR: tl ¢ 4,, raj
CHIMNEY (INDICATE BRICK/STUCCO/WOODFACED)
ROOF MATERIAL. PITCH (7/12 MIN.) I- j Cz czar
MAX. EXP f
WINDOWS (GRILLES REQUIRED) (WOOD/OTHER)
(INDICATE SIZES IF NOT LISTED ON ELEVATIONS):
0) 26" X <`l V
DOORS (WOOD/OTHER)
(INDICATE SIZES AND STYLE IF NOT LISTED ON ELEVATIONS):
3-0 k 6- L
TRIM: (ALL WINDOWS & DOORS TRIMMED WITH IX4 / IX5)
MATERIAL OF TRIM. (WOOD, VINYL, ALUMINUM) & 10 o d
SHUTTERS (WOODNINYL) (PANELED/LOUVERED)
GUTTERS (WOOD/ALUMINUM):
GARAGE DOORS: SIZE & STYLE:
STORM WINDOWS & DOORS:
(INDICATE SIZES IF NOT LISTED ON ELVATIONS)
SKYLIGHTS: TYPE/SIZE:
WOOD DECK: SIZE
WOOD FENCING (MAX. HEIGHT 6'): STYLE:
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
COLOR:
COLOR:
COLOR -
COLOR: Cu lca r c I
rx�i d
COLOR:
COLOR:
COLOR:
COLOR:
COLOR:
COLOR:
J! J
COLOR: ;
c N
RETAINING WALL. (P T OR FIELDSTONE - CONCRETE INAPPROPRIATE) = m
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
SIGNS: (indicate size, style, colors)
SIGN POST (indicate size, style, color)
N
-....,..s�..,., O
(`OLOR: 'O
COLOR:
'i� 'Uzi Cu.:i. ITTEE
L J e;J
y
7 0
IP--
2
CHICKEN COOP
F2o.JT
-? 'ktl
[� 0
7o
l
—A
nI TTEE
Ci•,'Fi,iD
•^PoSlY�.•
6cA[.E : A"= I'
T
5'6"
IT r
70 -'
--a
I ?
7' 9'L" � I-1 ;
C) N
=
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TI _{
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LEFT
;!TT
G,t1.;D fp
Cl
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' I
y�-
2/GHT
5Cr7LE ;'14 1'
Bog
\
ARMOUTH
ERK
^, 20 R 2: 09
_:1,r
R�� ,/ED
exrs-f/n9
chic%an
'Pan
proposed Lj ;h edr
chicken
pen
n// chicken a�
/ / r
rcr
ul j
-
�
ri -
r
Plan
show/n9ProPaSed chrekeo Coop ._
at
Taylor -Gray Farm
voc mo,f-h Pori
Mal7 97,zoo(, Scale:/"=5o'
Old King's Highway Regional Historic District Committee
in the Town of Yarmouth for a
APPLICATION FOR
CERTIFICATE OF APPROPRIATENESS
Application is hereby made in triplicate, for the issuance of a Certificate of Appropriateness, under Section 6
of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on
plans, drawings or photographs accompanying this application for:
CHECK CATEGORIES THAT APPLY:
-T�
1. Exterior Building Construction: P, New Building ❑ Addition ❑ Alteration
rn
3
Indicate type of building: C House ❑ Garage C Commercial COther
2. Exterior Painting: ❑
_M
Q
3. Signs or Billboards: ❑ New Sign ❑ Existing Sign G Repainting existing sign
<
rn 4
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other
M
tbl
7D =
TYPE OR PRINT LEGIBLY
N
W
DATE Fe-,L. /z 70c'
ADDRESS OF PROPOSED WORK / OS &ZO )qLf Ki Kam[ . IJO. ASSESSORS MAP NO.
OWNER /own ASSESSORSLOTNO. Z-i,
HOME ADDRESS TELEPHONE NO.
GENT RCONTRACTOR ��t -Zn'> Ye TELEPH�ONEN05-00-385-q-107
ADDRESS /0 3 �/-Ctt� �Lc nyr /�tl' . /moo . (�QtZ2f 0,-1�6 a c4ziP CODE 02 6 7 s
USE ATTACHED SHEET (PAGE #3) IN PACKET FOR ABUTTING OWNERS
DETAILED DESCRIPTION OF PROPOSED WORK: Give al! particulars ofwork to be done including materials to be
used In case ofsigns, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary).
SLtIC( 5J1eep 5itled USrnq Z'K-f' G�oris �rvcfron,
rest ceder roo-F r�htFe c�oGar sl�,n�lvs on 5t�f Kk:Cls.
d01 &,? , 6tJ rGJ -fr-Irtt
4 _'z ,,Date r-e-6. tz/ 2oa7
Owner-ContractoyLAgent is aware t at a Permit is required from the B
All new construction will be subject to inspection by OKH Inspector.
It is required that OKH approved (with BD stamp) plans are availab
and final inspections. I[
MAR 08 2007
Date This Certificate is hereby OLD KING'S`HI/GI
Check Date.✓�
By
APPROVED IMPORTANT: If Certificate is approved, approval is subject to the 10 day appeal
period provided in the Act.
DISAPPROVED ❑ PLEASE RETURN TO: Yarmouth OKHC District Committee
Yarmouth Town Hall, 1146 Route 28, S. Yarmouth, MA 02664
7040191
tv I FIELD COPY
BUILDING
PERMIT
APPLICANT Christopher Lee DATE July 26 2QQ9
PERMIT NO. R-O3—f'1R7
•� ADDRESS 85 Abells Rd pY 026�g
PERMIT TO ALTERATIONS )STREET) LCS Q8Qfi8�
RVPE OF IMPppyEMENTI I —I STORY NUMBERCOTK S LICENSE)
AT (LOCATION)
rv0.
)PFOFOSEp USE) DWELLINGG N
UNITS
am.-..,
—
_Q5_Rrav cn� ..
BETWEEN
m SUBDIVISION_�H 151_iY "-SS STREET)
a LOT BLOCK LOT
p SIZE
m BUILDING IS TO BE
T. WIDE BY
O FT LONG BY
Z —FT IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
s TO TYPE SR
¢-USE GROUP
O BASEMENT WALLS OR FOUNDATION
E REMARKS: Re DalTs t0 2[]d floor -floor Joists -addition of staircase $s ITYPEI
dated 7-19-02 er plans
AFEA OR
VOLUME
ICUBIGSpUARE FEET) ESTIMATED COST $ 2000 QQ PERMIT
OWNER Town Of Ya FEE $75.00
ADDRESS R
BUILDING DEPT / fgA/
BY
INSPECTION RECORD
vwg�"�
TOWN OF YARMOUTH Building Department gUILDING
(508) 398-2231 ext.261
PERMIT NO 8-03 087 PERMIT
ISSUE DATE 7/30102 - PROPOSED USE
APPLICANT •TOWN60YARMOUTH JOB WEATHER CARD
ADDRESS '11e6 Rrnge oa PERMITTO Alterations
AT (LOCATION) 100096BRAY FARM RD IN (-108) ZONING DISTRICT R-40
SUBDIVISION MAP LOT BLOCK 151.24 BUILDING IS TO BE USE GROUP R-4
LOT SIZE CONSTTYPE 5-B
removal of 2nd story floor joists, build Stairway to 2nd floor
REMARKS
\REA (SO FT) EST COST ($ $2,000.00 PERMIT FEE ($) $75.00
OWNER TOWN OF YARMOUTH
BUILDING DEPT BY
ADDRESS 11146ROU1028
CONTR'S 080884
LICENSE 0
CONTR'S NAME
Lee, Chris
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.
ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE APPROVED BY THE JURISDICTION.
STREET OR ALLEY GRADES AS W ELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBWC WORKS.
THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPUCANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM INSPECTIONS REQUIRED FOR ALL
APPROVED PLANS MUST BE RETAINED ON
WHERE APPLICABLE
SEPARATE PERMITS ARE
CONSTRUCTION WORK: 1) FOUNDATIONS OR
JOB AND THIS CARD KEPT POSTED UNTIL
FINAL INSPECTION HAS BEEN MADE.
REQUIRED FOR ELECTRICAL
FOOTINGS. 2) PRIOR TO COVERING STRUCTURAL
WHERE A CERTIFICATE OF OCCUPANCY IS
PLUMBINGIGASAND
MECHANICAL INSTALLATIONS.
MEMBERS (READY FOR LATH OR FINISH
REQUIRED, SUCH BUILDING SHALL NOT BE
COVERING) 3) FINAL INSPECTION BEFORE
OCCUPIED UNTIL FINAL INSPECTION HAS
OCCUPANCY 4) REFER TO DETAILED INSPECTION
BEEN MADE.
SCHEDULE
POST THIS CARD SO
IT IS VISIBLE
FROM
STREET
l /
2
2 .A / �
2
OTHER:
3
1
2
3
4
5
WORK SHALL NOT PROCEED
PERMIT WILL BECOME NULL AND VOID IF
INSPECTORS INDICATED ON THIS CARD
UNTIL THE INSPECTOR HAS
CONSTRUCTION WORK IS NOT STARTED WITHIN SIX
CAN BE ARRANGED FOR BY TELEPHONE
APPROVED THE VARIOUS
MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED
OR WRITTEN NOTIFICATION.
STAGES OF CONSTRUCTION
ABOVE.
X
ONE & TWO FAMILY ONLY - BUILDING PERMIT
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Town of Yarmouth Buildinti Department
1146 Route 28 • Yarmouth, MA 02664-4492
Tel: (508) 394 2231 z261 • Fax: (508) 399-2365
off' Use
Plannmg Board Information
Aesessors 6epartmenT tnfarma6on Quit
'.lot hta0
/�j�
Permit No. a
Pldn Type,
Map
Fee
Endorsement bate
Old --. -- New-
_ Permit .$ ✓l'
'
D "Date
Recormn bate
g
f.4 Property Dimensions
Deposit Rec'd, $ _
plan No
Net Due �$� ... d -7
Other -
-':Lot Area(sJ17,!(3 Frontage (ft) ,^ LotGoverege,-
"7fiis Section forDfficeUse
On"--
BUilding Permit Number. = Date Issued
f< aY Certlflcate of Occupancy
Signature[ - -Date
- udding,OPoc�at -
' ,s snot. requi
- -
Section 1 -Site ormation`. Use Group: R-4 Type: 5-B
.
11.1 Property Address'. {r
1.2 Zoning Information:
(7A24 �/ L -efl
Q L16
AC4766! net/ % /Zi( Oho 22—
Zoning District Proposed Use
1.3 Building Setbacks (n) elk) A,7
04/
Front Yard
Sid ards
Rear Yard
Required Provided
Required Provided Required Provided
r
r
a-Ot
0r
I Water Supply (M.G.L e. 40 S 54)
1.3 Flood ZonednfonnaGon.
Public Private
Zo ne:..= 8FE
Section 2 - Property 0wnei ship/Author iedAgent
2.1 Cv�eer o1 Record• (j
.�„,,, ryC,A?'14(51&4
C G % ""- /fir✓
-1�'
Mailing Address
Nam ri q
y 2"Z
O
`�
Signature
Telephone L V S 1
2.2 t/h'o�rized Agent:
I'
Name (print)
Mailing Address
alum Telephone
Section 3 - Construction Services
Not Applicable
3.1 Licensed Constructi n Supervisor.
r N em
License Number
A dress
V V
Expiration Date
!e
c�
Signature phone
gistere!Home mprovement- Contractny
Not Applicable ❑
Na
License Number
rAddress
Expiration Date
e Telephone
OVER
9 15-9
of 2
}
a
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes .......... No ..........
New Construction ❑ No. of
Existing Bldg. gepair(s)
Accessory Bldg, El Type
Brief�escription of P_roposi
Item
t
5. Fire Protection
6.70tal=0+2+3+4+5)
7 Total Square Ft. Irew hoses&
ns No. of Bathrooms
Alterations I Addition ❑
Estimated Cost (Dollars) to be
completed by permit applicant
Other Specify.
Check Below
❑ Conservation -Commission Filing
/ (if applicable)
Jam' Old Kngs Highway 8 Historical
"`��� Commission approval
(if applicable)
l, as owner of the subject property
hereby authorize
my behaiallttersrelative to wo�aulorized by this buildin to act on
gSpermit application.
Signature of owner lea
Date
as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
rnm name _ y
/ O Signature of Owner gent
Date
,r
oF�A,
_ \0
o
�y�
PLEASEPRIM
job Location:
Owner of Prol
TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
Construction Supervisor: l ���%%' L-�� ��O—dPY 141—�2'1/,r�
Name License No. cti...,. u,.
Address:
Licensed Designee:
(If other than Supervisor)
Name
2.15 Responsibility of each license holder:
License No.
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawi ngs
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuaii t to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discoven•of am -
violations which are covered by the building permit.
2.15.4 Anylicensee who shall willfullyviolate subsections 2.15.1, 2.152 or 2.15.3 or any other section of these
roles and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction. reconstruction.
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.152
Yes W No ❑
If you hav< checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance polic?RI'am
Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIV aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
V
The Commonwealth of Massachusetts
Department of Industrial Accidents
UI6
011leeal/arest/OatNis
600 Washington Street
Boston, Mass. 01111
Workers' Compensation Insurance Affidavit
ADDlicantinformation, p[easeZHI]N TedDdts
I am a sole proprietor 2r.d have no one working in any capacity
I am an emplover pros iding workers' compensation for my employees working on this job.
company name, ] 9xjl 61 Y',rw rsf / H
insurance m. policy N
I am a sole proprietor. general contractor. or homeowner (circle onef and have hired the contractors listed below who have
the followin_ workers compensation polices:
comoanv timm-
city, phone N:
Failure to secure coverage as required under Section SSA of MGL I53 cas lead to the imposition of criminal penalties ofa Gas op to Sl.Saa.90 and/or
one years' Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Doe ofS100.00 a day against sac 1 oadentandthat ■
copy of this statement may be forwarded to the Office of Investigation of the DU for coverage veriReadoa.
t do hereby tern nder the pains penalties f perjury that the information provided above is fore and correm
Signature r �C^=1 /�� I Date
Print name blyl- T ld3J i-, — 7///Y phone #
Official use only do not write in this area to be completed by city or town official
city or sown: xARrIDOTQ _ permitAicense # nBuilding Department
01.1cening Board
check if immediate response is required 261 pSeleem en's Ofnee
011calth Department
contact person: phone N;_ (508) 398_2231 eat, nOther
(,—M 3M v1A1
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
etttploy ees. as quoted from the "late", an employee is defined as every person in the service of another under any
contract of hire, express or implied. oral or written.
An einph rer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in ajoint 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
dyselliniz 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
%lGL chapter I section also states that even 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, 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 hay e
been presented to the contracting authority'
%p
Please till in the workers compensation affidavit completely. by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits 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
City or Towns
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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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
MCI of Imstlt'tlens
600 Washington Street
Boston, Ma. 02111
fax k: (617) 727-7749
phone #: (617) 727.4900 ext. 406, 409 or 375
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 260
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE:
JOB LOCATION:
4-hHOMEOWNER"
PRESENT MAILING ADDRESS
CITY OR TOWN STATE ZIP CODE
The current exemption for 'Homeowner' was extended to include owner — occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that such
homeowner shall act asup servisor. (State Building Code Section 108.3.5.1)
Definition of Homeowner:
Person(s) who owns a parcel ofland on which he / she resides or intends to reside, on which there is or is intended to
be, a one or two family attached or detached structure assessory to such use and / or farm structures. A person who
one home in a two-year period shall not be considered a homeowner, such "homeowner" shall
constructs more than ol on a form acceptable to the building official, that he / she shall be responsible for all
submit to the building ne home
such work performed under the building Permit. (Section 108.3.5.1)
The undersigned 'homeowner' assumes responsibility for cbmpliarrce with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimurn inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
�QMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements ofMGL Ch.142.
Yes No ❑
If you have checked yes please indicate the type coverage by checking the ap Bond t❑e box.
A liability insurance policy Other type of indemnity ❑
OWNER' S INSURANCE(tWAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent 0
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the 'reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work:
Address of Work
Address
Name:
Date of Permit Application:
I hereby certify that:
Est. Cost
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent o owner:
to ontractor N Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property'
Date
Owner Name
TOWN OF YARMOUTH
114GROUTE23 SOUTHYARMOUTH MASSACHUSETTS026644451-
Telephone (508) 898-2231, Ext. 251 — Paz (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDM
EUMMAL
GAS
PLUMBYG
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CAM Chapter 1, Section 1I1.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at/� &4%f 4G+2l m ��
' WorkAddrws // r
is to be disposed of at the following location: ✓L'U��/f/ditD/.Si���� p:—
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Z_
Signa Applicant Date
Permit No.
SUBMITTAL REQUIREMENTS / CHECK LIST FOR BUILDING PERMITS
New Structures
1. Application signed by the owner and owner's authorized representative / construction
supervisor. Application shall include: Construction Supervisor's License, Worker's Comp.
Affidavit / Certificates, Home Improvement Affidavit (all applications except new homes).
2. Six proposed site plans, stamped by a Mass. Registered Professional Land Surveyor, showing
all boundaries, proposed setbacks, existing & proposed grades / contours, proposed location
ofstructure(s), parking, curb cuts, drainage, impervious cover calculations (when applicable),
flood zone and Title V design and any other zoning related details deemed necessary.
3. Three sets of complete construction plans, including a complete structural cross section, floor
plans, use of rooms, dimensions, window & door schedule, HVAC details — electrical,
plumbing & mechanical plans are also required for commercial & multi -family (3 units or
more) structures.
4. Flood zone applicability — Compliance with Section 3107 of the State Building Code —
Elevation orJlood proofing certificates (whichever it applicable), shall be submitted prior
to the issuance of a certificate of occupancy.
5. Plans shall be reviewed by the following departments: Health, Engineering, Fire &
Conservation (when applicable). The Building Department will forward.
6. Old Kings Highway & Historical Commission (when applicable).
7. Mass. DPW approval for State Highway curb cut and access ways.
S. Construction control affidavits for all projects to be constructed or altered under the
provisions of Section 116 of the State Building Code. Buildingg containing 35,000 cubic feet
or more. One & two family structures are exempt; except wed designs maybe required
for unusual structural circumstances. Section 3107 of the Building Code requires certified
plans for new and substantially improved structures in flood zones.
Additions
1. Same as above, except the blank generic `Plot Plan' available from the Building Department
may be used for one & two family structures when setbacks are not marginal.
2. Flood zone applicability — When the value of improvements equals or exceeds 50% of the
structure value (substantial improvements).
Alterations
1. Same as above, except existing & proposed conditions shall also be shown on the plans.
NO WORK IS TO COMMENCE UNTIL THE BUILDING PERMIT HAS BEEN
ISSUED. Filing a building permit application does not imply approval and should not be
construed as permission to begin work.
INSPECTION SCHEDULE
NEW CONSTRUCTION, ADDITIONS & ALTERATIONS
The receipt of a building permit is not the end of the permit process, but rather the
beginning. The building permit holder is responsible for arranging the required
inspections before proceeding with additional work. Failure to do so may result in
having to expose concealed work through the partial or complete removal of some
building elements, causing you delay and unnecessary expense.
It is imperative that you arrange for the following inspections by either calling 508-398-
2231, extension 261, or make a personal request at our office at least 49 hours in
advance:
FOUNDATION
• After certified 'as built' site plans have been submitted
• Before concrete floor is poured
• After perimeter drain has been installed
• Before backfill
• Before first deck is constructed
• After damp proofing
• After certified flood cone elevations have been submitted (when applicable)
Note: When proposed plans specify re -enforcement rod installation or
other unique design criteria you are required to call for an inspection
prior to pouring the concrete. In some cases a separate inspection may
be required for a stratalsoil or footing inspection.
FRAME
• After rough electrical, plumbing & gas approvals have been made
Before insulation
• After being made tight to the weather
FIREPLACE / CHIMNEY
When smoke chamber is complete
When chimney is complete (may be inspected with frame)
Final
INSULATION
• After building envelope is completely insulated
FINAL
• After all other inspections have been approved
• After electrical, plumbing, gas & fire inspections have been approved
• After all wolicable historical applications have been completed
DFY�R TOWN OF YARMOUTH
�o BUILDING DEPARTMENT
is jjgg®®0 ' �\
IOI i-3
°s���,,.•°,' BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
p TRANSMITTLAL SHEET
Building Site Location: / 4 �/U/mly jI-/tt� Map No: /$ / Lot No:
Proposed Improvement:
Address:
The Building Department
_applicable departments.
Filed: '7 12?/1
responsible for assisting the applicant by dispatching your plans and or application to the following
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT:
Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT
Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION:
Detemmnes Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
"HEALTH DEPARTMENT:
Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT-
Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
-------------------------------------------------------------------------
--------------------------------------------------------------
REVI ?WED BY:
1. WATER DEPARTMENT:
DATE: N/A:
2. ENGINEERING DEPARTMENT:
DATE: N/A:
3. CONSERVATION:
DATE: N/A:
4. HEALTH DEPARTMENT:
DATE: N/A:
INDUSTRIAL AND/OR COMMERCIAL PERMITS
S. WRING INSPECTOR: DATE: N/A:
6. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT:
PLEASE NOTE
rnvvowmc.
RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE:
Waite copy—Buadiug Dept - Yellow Copy —H®Ith Dept - PWc Copy—Eug�gDcpt. - Goldemod-Fhe DcptACaasavzriou
o.. TOWN OF YARMOUTH
Building Department
s Town Hall
Yarmouth, MA 02664
(508) 398-2231 eM.261
BBUILDING PERMIT
APPLICATION RECEIPT
Temp Permit No.: T-03-041
Applicant Name: Chris LeelTown of Yarmouth
Location: 00096 BRAY FARM RD N (-108)
Owner's Name: TOWN OF YARMOUTH
Owner's Addres 1146 Route 28
South Yarmou MA 02664
Owner's Telephone: (508) 398-2231
(OFFICE USE ONLY
Recorded By:
Ic
Permit Fee:
$0.00
Deposit Rec:
$0.00
Payment Type:
Check ChkNo.. 0
Net Owed:
$0.00
Application Date:
7/19/02
Issue Date:
Expiration Date
Comments:
removal of 2nd story floor joists, build stairway to
2nd floor
This is NOT a building permit. Application subject to plan review. Contact Building Department for permit status. Official
Building Permit will be issued upon plan review completion, approval, and complete payment of Net Owed on Permit Fee.
Date Printed: 7/23/02
Erc+.vne -Opens K� ann.u+ CuPocil - E4>CLI
xew,Gve o,
tS7tom) Sv w l LJ'4/,,L( s
GF S ZFS - Sonne �.t r.Vh PCB ov Tto c�e�,
•,,.,,.,,r rt. t?e ,l<.-cE' c�1\ t'.xt;1u_`1 taco' �ocvr;
t
-+- vFe.�\o,ce Tl.�- cenn't,
_. C'XSTr�n-a, t5 c1c-pw.H�U.4Ti�✓..
a r TOWN OFYARMOUTH BuildingDeparnlent BUILDING —^
j (508) 396-2231 ext.261
PERMIT NOISSUE - :: :1,- PERMIT
�... ISSUE DATE 4l12 Q" _ PROPOSED USE
APPLICANT 'dha"dar,;�y JOB WEATHER CARD
PERMIT TO MiscJten
----------
AT (LOCATION) 10DO96BRAY FARM RO N (-108) ZONING DISTRI R-40 al lg. Type: Reswlentiel
SUBDIVISION MAP LOT BLOCK 151.2d BUILDING IS TO BE: CONST TYPED USE GROUP
LOT SIZE O
REMARKS temp ten: duration 528/04-5/30/04
AREA (SO FT) EST COST ($ 5700.00 PERMIT FEE ($)
OWNER ITOWN OF YARMOUTN BUILDING DEPT BY
ADDRESS t118 Route 28
CONTRACTOR
LICENSE
POB 48
Mattapolse8 MA 02739
8006492055
INSPECTION RECORD FIELD COPY
�. obi=PA
��1j L
0 «:imadt
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261
0ONSTRUC110NADDRM;
ASSESSOR'S 04ZORMATION:
M+v� 1571 Parcel: Zq
OWNER: ZRo/J of .Y/'MouTN
NAM PRESEW ADDRESS Tn. d
K
❑ Residential ❑ Cman«dd Es. Cos of CorWtRtim S_ # 7o0 . C, 0
Rome hoptrvaeatt Cmbww Ur- N Conamc ion Stpavisor lia 0
Worlmun's Campmudm kmre«: (chock cow)
❑ 1 not the haneuvrner ❑ 1 an the sole papridw ❑ 1 hue worker's Caoperoedm Imtrutoc
hmaance CmVery Natte: Worker's Cane. PW"
WORK TO BE PERFORMED
tJ'Tatr (Pre Retsedrw CeoSwasaoMd)
Dwai« Ma3e Wood Steve Sbed
❑ Simas! d ofSgr«s O Rop4«ort windo d
OR doors r
❑Ra f dofSperes
()Swww1rowsks6 s l)paRVICK ayas Ofasdriaaeeof yn�
•ILe debris wilbedepmdofo
Lsweow ofFactTky 1
I de bre ew err PdN^s efperjory the for lrlrooa bgei eaaaisedste or and «erect to the bee of wy ksewfedp W W vL 1 rdoeoi *A ap him suwa(s)
will bs just on« for dell a sesaosd« of eq lie«w W for poagpiirder KO-L Ch. 26k Sectim 1.
Appliosw's S4POWr )/2)- ��- �C.'J t2c) Deb �2. SI2,rr—,:Ld
scss-R
owwna Si`r«rs (w athointr) � D.te
Approved By: Ds
Bv"mg Ofcist (w do ip«)
Zoning District; 4 110
Historical District: Yes ❑ No Flood Plain Zone: (p" . ❑ No
Water Researee Praeaim District: Within 100 R of Wetlands;
0 Yes p No ,pJ Yes 0 No
CTPr�tfirttte of �R1�tntP �p.�i�tttltrE
REGISTERED a• a c /F o ISSUED BY
APPLICATION }�°= INC. NUMBER � 5 ANCHOR INDUSTRIESDate of Manufacture
EVANSVILLE, INDIANA 47711
2
FJOO2 ty /RE P pr MANUFACTURERS OF THE FINISHED
RE �a TENT PRODUCTS DESCRIBED HEREIN T2012 4/1/89
This is to certify that the materials described have been flame-retardant treated (or are
inherently noninflammable) and were supplied to:
NAME: Chase Canopy Co.
------------
CITY Mattapoisett STATE MA
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 Marshall Code, equal to or exceeds NFPA 701, CPAI 84 Part 3.5.9 of CCc-C-42BE (also
Method of application: IMPREGNATED c1 gified by UL Flammability only 3541)
Type, color and weight of canvas/vinyl: 12 oi. Gala Pink/White
Description of Item certified: 40 x 120 6pc. Sq. End Party Tent
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabri
L7c
f:rf irevi lie Comnanv
Name of Applicator of Flame Resistant Finish
Graniteville, SC
Signed:
TENT DEPARTMENT—gNCMOR INDUSTRIES INC.
Louie R. Brown
TOWN OFYARMOUTH BulldingDepartment BUILDING
(508) 398-2231 ext.261
PERMIT NO B-06-1455 ___ -_ _- PERMIT
ISSUE DATE 618/2006_ _ : PROPOSED USE PERMIT
APPLICANT 'c secanopv - _ _ - JOB WEATHER CARD
oum Tn A,tier Mmt -
AT (LOCATION) 100108BRAY FARM RD N ZONING DISTRICT R-4 Bldg. Type: Residential
SURDIVISION MAP LOT BLOCK BUILDINGISTOBE: CONST TYPE USE GROUP R-4B
LOT SIZE
erect temporary tent - durat m: GW6. 06105M6
REMARKS
TFE)
AREA (SO FT) EST COST ($ $0.00 PERM
OWNER T0or- Bray Farm/Town of YamauO ___j BUILDING DEPT BY
ADDRESS 1114BRoute28
INSPECTION RECORD
CONTRACTOR
LICENSE
Chase Campy
4 Nickys Lane
Mattg=eu MA
8006492055
PHONE 150839BM1
FIELD COPY
of H,1
TOWN OFYARMOUTH
Building Department
BUILDING
+
(508) 398-2231 ext.261
PERMIT NO B-06-1455_
PERMIT
�.
ISSUE DATE : 618/2006 ,
PROPOSED USE
_ _
_ _ _ _ _
-
APPLICANT :Chase Canopy- - -
--- -------------
- - - - - - - - -
- - - - --
JOB WEATHER CARD
PERMITTO Misc-Rant
------------
AT (LOCATION) 100108BRAY FARM RD N
ZONING DISTRICT R-4
Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 151.24.1
BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-4
LOT SIZE
erect temporary IBM - duration: GW6 - 06/05/06
REMARKS
AREA (SOFT)
OWNER
AnnRFSS -
EST COST ($
0
PERMIT FEE ($)
BUILDING DEPT BY
CONTRACTOR
LICENSE F
Chase Canopy
4 Nickys Lane
Mattapdsett MA
8006492055
Sarah YaRRaAh MA 1026U I PHONE 511839A2231
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.
ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE APPROVED BY THE JURISDICTION.
STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEW ERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBWC WORKS.
THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM INSPECTIONS REQUIRED FOR ALL
APPROVEDPLANS MUST BE RETAINEDON
WHERE APPLICABLE SEPARATE
ARE REQUIRED
CONSTRUCTION WORK: 1) FOUNDATIONS O R
JOB AND THIS CARD KEPT POSTED UNTIL
FINAL WSPECTK)N HAS BEEN MADE.
ELECTTRICAALL
FOOTINGS. 2 PRIOR TO COVERING STRUCTURAL
WHERE A CERTIFICATE OF OCCUPANCY IS
AND MECHANICAL
MEMBERS (READY FOR LATH OR FINISH
REQIR UED, SUCH BUILDING SHALL NOT BE
INSTALLATIONS.
COVERING) 3) FINAL INSPECTION BEFORE
OCCUPIED UNTIL FINAL INSPECTION HAS
OCCUPANCY 4) REFER TO DETAILED INSPECTION
BEEN MADE.
Af.HFnIIIP POST THIS CARD SO
IT IS VISIBLE FROM STREET
BUILDING INSPECTIONS APPROVALS
1
t
1
/
1
2
2 \ /
2
3
OTHER:
1
S
l
2
3
4
5
WORK SHALL NOT PROCEED
PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION
INSPECTIONS INDICATED ON THIS CARD
UNTIL THE INSPECTOR HAS
WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE
CAN BE ARRANGED FOR BY TELEPHONE
APPROVED THE VARIOUS
PERMIT IS ISSUED AS NOTED ABOVE
OR WRITTEN NOTIFICATION.
STAGES OF CONSTRUCTION
oc r�
TOWN OFYARMOUTH
Building Department
BUILDING
(508) 398-2231 ext.261
PERMIT NO B-06-1455
PROPOSED
PERMIT
ISSUE DATE ," 6/8/2006
USE
APPLICANT'chaseCanapy
JOB WEATHER CARD
PERMIT TO MiscReM
AT (LOCATION) J00108BRAY FARM RD N
ZONING DISTRICT R-4
Bldg. Type: Residontial
SUBDIVISION MAP LOT BLOCK
LOT SIZE
erect temporary tent - duration: 8/3r06 - 06105/06
REMARKS
BUILDING IS TO BE: CONST TYPE 5-B I USE GROUP
AREA (SO FT) EST COST ($ $0.00 PERMIT FEE ($) $O.W
OWNER Taylor- Bray Farm/Town of Yamxwih BUILDING DEPT BY
ADDRESS 11146Route28
South Yarmouth LhM02664
YOUR SPECIAL ATTENTION Is called to the following
CONTRACTOR
LICENSE 0
Chase Canopy
4 Nickys Lane
Matlepoisett MA
8006492055
PHONE 150&19=31
This permit is granted on the express condition that the said construction shall, in all respects, conform to the Ordinances of this
jurisdiction including the Zoning Ordinance, regulating the construction and use of buildings, and may be revoked at any time upon
violation of any provisions of said ordinances.
Weatherproof placard given at the time permit is issued must be displayed m premises. The Department must be notified and Inspection made of prior
construction work as requested on weather card. All new buildings and additions and alterations to existing buildings require a minimum of three called
inspection, namely, 1) Footings, drain tile systems, foundation and basement walls, when walls we at least two feet high, but before back fillings the wall and
before proceeding with the superstructures. 2) Framing prior to lath or finish covering but attar firestopping, electrical, plumbing and mechanical systems are
installed. 3) Final inspection when building or structure is completed.
On jobs involving reinforced concrete work, Inspection must be made after steel is in place and before concrete is poured.
The Department reserves the right to reject any work which has been concealed a completed without first having been inspected and approved by the
Department in accordance with the requirements of the various codes.
Any deviation from the approved plans must be authorized by the approval of revised plans subject to the same procedure established for the examination of
the original plans. An additional permit fee is also charged predicated on the extent of the variation from the original plans.
Permits are not valid t construction wont is not started within six months from date permit is issued.
Request for Final Inspection should be made by postcard or phone call to this department when the construction work Is completed and hearing
apparatus has been installed. Painting or decorating is not required before the Final Building Inspection.
Final Inspection and certificate of occupancy must be obtained before occupying buiding.
APPLICANT COPY
��jo$ 37d 083(0
ot'YAR
O �H
EXPRESS
CONSTRUCTION ADDRESS:
dPermit 8 0 -
Fee$ A—e-f✓'e
MAY 2�06 Permit expire 6 months from .
issue date.
UILDING PERNUT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261
Pci'. A,), 1,&,wto &N po
ASSESSOR'S MFORMATION: r et/X ~
Map: ! Parcel:
OWNER: �d W.0 010
NAME PRESENT AD/DRESS
CONTRACTOR
❑ Residential ❑ Commercial EsL Cost of Construction
Home Improvement Contractor Lic. d Conswction Supervisor Liu N_
Workmen's compensation lnsmsnce: (check one)
❑ 1= the homeo"cr ❑ 1 am The sole proprietor ❑ 1 have Worker's Compensation Inrasnce
Insurance Company Name: Worker's Comp.
-G
WORK TO BE PERFORMED
Tent (Fire Retardant Certificate aDo.m) ,� „p _/p oN S�,yg wood stove shed
Duranen Lr2c/ (VKu�+�na.1-�S
❑ Sid rdi, Y of Squares ❑ Replacement windows: 8
Cl Replacement doors: 8
❑ Reaoof 8 of Squse
() Stripping old shmW () going wa Iayam ofexiatheg roof
o267S
- ZoS5-
-The debris will be disposed of at
Location of Facility
i declare under penalties ofpajury that the srmments herein codamed are true sod correct to the best of my knowledge and behaf 1 understand that any false answer(s)
will be just mrse for denial w 9vocation of my licenjp a d for prosecution undrMO.L Ch. 268, Section 1.
Applicant's Sign itu :
6G8
Approved BY: ing ODar:
Buildfficial (or
5- 23-0C.
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District Within 100 R of Wetlands:
❑ Yes ❑ No ❑ Yes ❑ No
3/01
Department oflndustrid Accidentsu
O,Q4ee of lnvest(rations
600 Washington S&m
Boston, MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
Aonlicant Information Please Print Legibly
Name (BusingaOran/hdividual):
Address:
City/State/Zip: Phone M
Are you u employer? Checkthrappropriate box- Type of project (required):
1. ❑ I on a employer with 4. ❑ I am a general contractor and I
employees (fig and/or part-time).• have hired the subeonticans 6. ❑ New construction
2. ❑ I am a sole proprietor orparrtoer- lined on the attached sheet = T ❑ Remodeling
ship and have no employees These sub -contractors have 8. ❑ Demolition
working for me in any capaft workers' comp. insmauce. g ❑ Building addition
[No workers' comp. numance S. ❑ We are a corporation and its .
required.] offixers have exercised their 10.Q Electrical repairs or addition
3. ❑ I am a homeowner doing an work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself (No workers' comp. e.152,)1(41 and we have no 12.❑ Roof repairs
insorance required ] T eroployees. [No workers' 13.[] other
comp• insurance requirM.]
1 mo�wwms dMcb0dmb=si1 sho M odthe scion bdow&owingOak Poilmn' orngms.Oba pulley fiLamstba
tcontrsbrs lbd chock Sb box mW mscbs tldM And showing dw amn of&e saconuadm djr sue. poft idbrn tim
gasp poary iaforrrsttoa
law an earp/oya that Ir provldtag workers' compewaska ins a jet aryearployees. Below it the pefley awd job sNe
hsfennaaoa.
Insurance Company Name
Policy # or Self-im. Lit # --E,xnvatiae Dom.
Job Site Address: \
Attach a copy of the workers' compensation
Page (showing the policy number and explratlou date).
Failure to secure coverage as rcgoIIed 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 imprisonmen% as wen as civil penalties in the form of a STOP WORK ORDER and a fore
of cup to $250.00 a day against des violator. Be advised that a copy of this statement maybe forwarded to The Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cndjy under the pabrs and perrabks ofpedwY that the Injormadon proW&d above Is true and correct
01kfil we enlyw Do rear wr6e In this area, to be compkied by city or town ojklst
City or Town:
rermitlucenae
Issaing Authority (circle one):
1. Board of Health L Building Department 3. Cltyfrown Clerk 4. BlecbiW Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone
lntormation anti ivail u1lw%,JL Vasa
Mass General laws chapter 152 requires an employers to Provide workers' compensation for their employees.
Pmanaut to this stata0e, an ewploym 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 rngdBcd in a jointeIIG and inc)uding the legal represeatstivea of a deceaseemployer, er, Or the
receiver or trustee of no individual, pattership, association or other legal entity, employing employem However t o
owner of a dwelling house having not more flan three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persona to do maintenance, conscuction or repair work on such dwelling boom
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,125C(6) akso states that "every state or local licensing agency shall withhold the Issuance or
renews, of is license or permit to operate a business or to construct buildings In the commoaweslth for any
applicant who has not produced acceptable evidence of compliance with the insursace coverage required.
Additionally, MGL chapter 15Z ¢25C(7) states "Neither the commonwealth nor say of its political subdivisions ainsurancanc
enter into any contract for the performance of public work until acceptable evidence of compliance with die e
requirements of this chapter have been presented lo the contracting authority."
Applicants
Please fill out the workers' con4msation affidavit coanpletely, by checking the boxes that apply to you situation and, if
necessary, supply sub -contractors) uls ue(s), xMress(cs) and phone number(s) along with their certificate(a) of
insurance Limited Liability Compa
nies (LLC) or Limited Liabitity Partoerahips (LLP) with no employees odher than the
members or Parmaa, are not required to cant workers' compensation insurance If an LLC or 1 I P doer have
emloyees, a policy is required. Be advised that this affidavit may be submitted In the Department of Industrial
Accidents fbr confirmation of insurance coverage. Also be acre to sip and date the aflfdaviL The affidavit should
be returned to die city or town that the application fro the Permit or license is being requested, not the Department of
Industrial Accidents. Should you have say questions regmdmg the law or if you are required to obtain a workers'
eoaeensation policy, please can the Department at the number listed below. Self insured companies should enter their
city or Tower Officlab
Please be sure that the affidavit is compte an
d printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigation has to contact you regarding the applicant
please be sure to fill in the perroW icense number which will be used as a reference number. In addition, an applicant
that Est submit n *lc permMcrose applications in any given year' need only submit one affidavit indicating cmrent
policy kformadon (if necessary) and under "Job Site Address" the applicant sbould write "alllocations in (city or
town}" A copy of 111e affidavit that has been officially stamped or marked by the city of town may be I MOd to the
applicant as proof that a valid affidavit is on file for fntnre permits orlicenses. Anew affidavit muatbe IMed out each
year. Where a bums owner or citizen is obtaining a license of permit not related to any business or commercial venture
(ie. a dog license or permit to bran leaves eta) said person is NOT required lo comp
lete this affidaviL
The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions,
please do not hesitate In give us a call.
The Departmcntb address, telephone and fax tnnobes:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26.05 wwwmm.gov/dia
05/24/2006 16:26 NO.679 002
rrun..vin-I —t`AITPWmC Al: 61V Irewance Agency F"ID: To: Anson paw; 524A6 01:41 PM Page: 1 of 3
ACORD CERTIFICATE OF LIABILITY INSURANCE °,se 3 DA OS 124/ 6
PROOUCeR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Herry Insurance Agency MOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
300 Congress St Suite 306 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Quincy MA 02169
Phone:617-479-5500 Fax 617-479-6761 INSURERS AFFORDING COVERAGE NAICN
II lSURED'-
-It 11.1 'Al. f IfU]11C I.G. CO.
-.0"PERb Onesea COR InS.--Grp
chase Canopy Company, LLC -
Dangel Chase INSURER _ AIOInsurance Company
4 Micky s Lane E_O- IrvsuPEP D' Box 46 -
Mattapoisett Ai 02739
11111r I" F-:=,�P-NtE LISTED 111,A,11N:, Shhu 5i'_E': r+-HE INSUPEC' IUECI ,<fly.-.1ML'-:tk r FEFIOD INVCAIED. N•T^ninL'•IDIb'-
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AUTOMOBILE LIABIl1TY
I
B -F AI°i-LM% CBXM51701
05/21/06
05/21/07
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DESCRIPTION OF OVENATOUS: LOCATIONS J vENICLFS I EV1uSION4 gDDE9 BY ENDORSFlAFN1 / SPECSAL PROVISIONS
Operations usual to tent and Canopy rental/Event dates: 6/2106 - 6/5/06
PCE ICu-eTc unr non
Taylor Preservation Assoc.
sheep sheering Benefit
106 Bray r.=
Yarmouthport MA 02615
TAYLORP SHOULOANYOFTHE ABO'A DES
PJCRIBED POLICIES BG CANCELLED BEFORE THE EA'PIRATION
GATE THEREOF. THE ISSUOINBURGR WILL ENDEAVOR TO MAC 10 Or's WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO 00 SO SHALL
IMPOSE NO OBLKAnsel OR LIABILITY OF ANY KIND UPON THE NSURER. ITS AGE,, cR
fflnrsrsss�n�n�n�rfrn�nsr PR500l nl��n�nt n�mynrs>s�l I M P O R T A N T D U C: U M != N 1 uuuuuuuuuu��>Jm�
N
Certif irate of flain � i��i
ISSUED
REGISTERED is
Date of MamAPPLICATION ® 3/:m
NUMBER INOUsiRPi EVANSVILLE, INDIANA 47711 Order
F140.O1 21_
MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardan-
(or are inherently noninflammable) and were supplied to: TL yalw=
CHASE CANOPY COMPANY
4 NICKY'S LANE
P O BOX 46
MATTAPOISETTE MA 027390406
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant
chemical and that the application of said chemical was done in conformance with -Caiil
Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109.
The method of the FR chemical application is:
Serial N:
Description of item certified: CENT END 40W X 20 LO VL W W
(0001)
Flame Retardant Process Used Will Not Be Removed tsy o
Washing And Is Effective For The Life Of The Fabric
SNYDER > NEW PHMADELPHM B
Name of Applicator of Flame Resistant Finish
Signed: Nt�a -./,) his.+
TENT DEPARTMENT —ANCHOR INDUSTRIES IN m
PrlcPc ncPrlcPcPcPcPcPrJ�rJ�rJr�cPrJ�JdJ�rJcPcPcPcPrJ�cPJi IMPORTANT DOCUMENT aPJJ�LPsLP�J�J�J�sJsJ� N
• •, N
N
REGISTERED
APPLICATION
NUMBER
F140.01
4f flame
�eNINDUS MS INC.a
EVANSVII I E, INDIANA 47711
ANUFACTURERS OF THE FINISHED
ANT PRODUCTS DESCRIBED HEREIN
N�� COD D1r
05,198 M a
Order Number
181585
This is to certify that the materials described have been flame-retardant treated
(or are inherently noninflammable) and were supplied to: 7�c_ ypX�p�
CHASE CANOPY COMPANY
4 NICKYS LANE
P O BOX 46
MATTAPOISETTE MA 027390406
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, equal to exceeds HFPA 701, CPAI 84, ULC 109.
The method of the FR chemical application is:
a:
8140z00
(0001)
Description of item certified: CENT END 40W X 20 HO VL W W
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric Z
0
Signed: e Q
Name of Applicator of Flame Resistant Finish TENT DEPARTMENT —ANCHOR INDUSTRIES INC. �0
PcPU�JrJ�cPcPc.PJrJcPcPcPrJ�r.PrJ�rJ'cPcP�.fr�cPrlcPrJ'r�cPcPcPrPrJ@P�J'rJ�rJ�rJ�rJ�rJ@PcP�.fU�rJ�rJ'�PcPcPPrJ�r.PrlrJrJrJ�rJ@PcPcPcPcPtJJ'cPcPcPrJrJ�rJ�PrJ�rJ�r�rJ�U�rJ
m
N
�'1'�'�'�'u'R'RI'� 31`12 ���a,�� IMPORTANT DOCUMENT
Certificate of f famic
REGISTERED ISSUED BY
APPLICATION
NUMBER �: A�"
ES INC.
FI40.1 r EVANSVILLE, INDIANA 47711
. m
�.e�i�tacr�tQ
MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have
(or are inherently noninflammable) and were supplied to:
CHASE CANOPY COMPANY
4 NICKYS LANE
P O BOX 46
Date of Manufacture m
05/26100 A
Order Number
319211
been flame-retardant treated
j c �1 Xav�-
MATTAPOISETTE MA 027390406
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, equal to exceeds NFPA 701, CPAI 84, ULC 109.
The method of the FR chemical application is:
Serial #:
6140300(t)
Description of item certified:
CENT END 4o W X 20 LO VL N W
_ Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
✓�.--� e o
SNYDFRMFG NEW PHfIADELPHIA,OH Signed: -
m
Name of Applicator of Flame Resistant Finish TENT DEPARTMENT —ANCHOR INDUSTRIES INC.
PcPr�rJ�cPrJrJ�rJrJrJ�cPcPcPcPrJ�rJcPcPr�cPr�cPrJ�cJ�cPcPcPrJrJrJ�rlcPTJ�cPrPrJrJrJ�rJ�rJ�rJ�rlrJ�rJ�TJ�rJr�U�rJ�r�rJ�UcJ�focPrJrJ@PTJ�rJrJ�cPrJUr�cPrlrJ�rJ�cPrlr�rJrJ�rJ�c.PcPcP o
m
w
TOWN OFYARMOUTH Building Department BUILDING
9 (508) 398-2231 ext.261
=' PERMIT NO B-06-1457 PERMIT
ISSUE DATE-6/8/2006 - PROPOSED USE
APPLICANT 'Eamitacle&ani Shwiff's-Daum i JOB WEATHER CARD
------- -- -- ---
PERMITTO MisCAent
AT (LOCATION) 100108BRAY FARM RD N ZONING DISTRICT R-40
SUBDIVISION MAP LOT BLOCK 151.24.1 BUILDING IS TO BE: CONSTI
LOT SIZE
Imp. tent - duration: SfM6. 06/05/06
REMARKS
AREA (SO FT) EST COST ($ ISO•'
OWNER I Taylor- Bray Femirrown of Yarmouth
ADDRESS 11146ROuIO28
South Yarmouth I MA 102664
UH
PERMIT FEE ($) C
BUILDING DEPT BY
Bldg. Type: Residential
'Ea USEGROUP[—
CONTRACTOR
LICENSE 0
PHONE 1508398Ml
INSPECTION RECORD FIELD COPY
of-pq
TOWN OF YARMOUTH
Building Department
BUILDING
T
(508) 398-2231 ext.261
.�
PERMIT NOT
' PERMIT
ISSUE DATE 6/812 06
PROPOSED USE
- - - — -6
APPLICANT 'BemetebleCountyshwff-fsDepaeni
........ .. ..
- -;
.. . . .
JOB WEATHER CARD
PERMIT TO MiSCAent '
AT (LOCATION) 100108BRAY FARM RD N
ZONING DISTRICT R-40
Bldg. Type: Resltlentiel
SUBDIVISION MAP LOT BLOCK
LOT SIZE
temp. tent - duration: 6rV06 - 06/05M
REMARKS
AREA (SO FT)
OWNER
ADDRESS
EST COST ($
BUILDING IS TO BE:
PERMIT FEE ($)
1=P114AC[HUA�l-S1
z
USE GROUP
CONTRACTOR
LICENSE 0
PHONE 1=98=
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.
ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE APPROVED BY THE JURISDICTION.
STREET OR ALLEY GRADES AS W ELL AS DEPTH AND LOCATION OF PUBLIC SEW ERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLUC WORKS.
THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE OONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM INSPECTIONS REQUIRED FOR ALL
APPROVED PLANS MUST BE RETAINED ON
WHERE APPLICABLE SEPARATE
PERMITS ARE REQUIRED FOR
CONSTRUCTION WORK: 1) FOUNDATIONS OR
JOB AND THIS CARD KEPT POSTED UNTIL
ELECTRICAL I NGIGAS
FOOTINGS. 2) PRIOR TO COVERING STRUCTURAL
FINAL WSPECTON HAS BEEN MADE.
WHERE A CERTIFICATE OF OCCUPANCV IS
APLU
MEMBERS (READY FOR LATH OR FINISH
REQUIRED, SUCH BUILDING SHALL NOT BE
INSTALLATIONS.
COVERING) 3) FINAL INSPECTION BEFORE
OCCUPIED UNTIL FINAL INSPECTION HAS
OCCUPANCY 4) REFER TO DETAILED INSPECTION
BEEN MADE.
cr.NFnIII F POST THIS CARD SO
IT IS VISIBLE FROM STREET
BUILDING INSPECTIONS APPROVALS
1
1
1
2
2 \/
2
3
OTHER:
1
2
3
4
5
WORK SHALL NOT PROCEED
INSPECTIONS INDICATED ON THIS CARD
PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION
UNTIL THE INSPECTOR HAS
WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE
CAN BE ARRANGED FOR BY TELEPHONE
APPROVED THE VARIOUS
PERMIT IS ISSUED AS NOTED ABOVE
OR WRITTEN NOTIFICATION.
STAGES OF CONSTRUCTION
of F�q
TOWN OF YARMOUTH Building Department
BUILDING
t
(508) 398-2231 ext.261
B- 06-145�_
PERMIT NO
PERMIT
ISSUE DATE PROPOSED USE
_6/at2006_ _
APPLICANT 'Bametable County Sheriff's Depadmerii - -'
.. . . .. .. . . . .. ..
JOB WEATHER CARD
PERMIT TO MiscAeM
AT (LOCATION) 100108BRAY FARM RD N ZONING DISTRICT Rd0
Bldg. Type: Residontlal
SUBDIVISION MAP LOT BLOCK 1151.24.1 BUILDING IS TO BE:
LOT SIZE
temp. tent - duration: 6r" - 0WMS
REMARKS
AREA (SO FT) EST COST ($ $0.00 PERMIT FEE ($)
OWNER I Taylor- Bray FamVraxn of Yarmouth BUILDING DEPr BY
ADDRESS 11146ROW028
South Yarmouth LW W4
YOUR SPECIAL ATTENTION Is called to the following
USE GROUP
CONTRACTOR
LICENSE 0
PHONE 150839112231
This permit is granted on the express condition that the said construction shall, in all respects, conform to the Ordinances of this
jurisdiction including the Zoning Ordinance, regulating the construction and use of buildings, and may be revoked at any time upon
violation of any provisions of said ordinances.
Weatherproof placard given at the time permit Is issued must be displayed on premises. The Department must be notified and inspection made of prior
construction work as requested on weather card. All new buildings and additions and alterations to existing buildings require a minimum of three called
inspection, namely, 1) Footings, drain the systems, foundation and basement wells, when walls are at least two feet high, but betas back fillings the wall and
before proceeding with the superstructures. 2) Framing prior to lath or finish covering but aka firestopping, electrical, plumbing and mechanical systems are
Installed. 3) Final Inspection when building or structure is completed.
On jabs involving reinforced concrete work, inspection must be made aka steel is in place and before concrete is poured.
The Department reserves the right to reject my work which has been concealed a completed without first having been inspected and approved by the
Department in accordance with the requirements of the various codes.
Any deviation from the approved plans must be authorized by the approval of revised plans subject to the same procedure established for the examination of
the original plans. An additional pemtit fee is also charged predicated on the extent of the variation from the original plans.
Permits we not valid if construction work is not started within six months from date permit is Issued.
Request for Final Inspection should be made by postcard or phone call to this department when the construction work is completed and heating
apparatus has been Installed. Painting or decorating is not required before the Final Building Inspection.
Final Inspection and certificate of occupancy must be obtained before occupying buiding.
APPLICANT COPY
'M0TT�D
MAY 2 "006
EXPRESS BUILDING PERNM APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Deparlmmt
1146 Route 29
South Yarmouth, MA 02664
(509) 399-2231 Ext. 261
❑oNgmuenONADDRM: 108 232!a f a/30( le-1 /Jo , 41VW ,o uw f ot--�
ASSESSOR'S ROX MATION:
Map: /S/ Parcel: OFT-1
owmm: L�-g
HAbffi fR111TADDRC4a TEL
MKMACMR:L71/1i5Q/e L-* �Gtert�'t 'S L�P7
NAA18 MAMM ADDUSS TE"
❑ Raddeodal ❑ Cam namw Est Caet ofCOMMEdW $
Nome Wprovcmae Cmhacew lk a Caosmcdm Snpmvisor 1la, a
wabamn's Cumpauedm hmnanca (dwdcme)
❑ lam the hmm a l em the We pop item ❑ 1 hsa Woea •a Campemedm hmamoe
douses Company Name; war w•a Camp. Pol]rya
WORK TO BE PERFORMZD
Teat Q%ReWrdmtCwdficWaacled) z f orr .Tun3
Deadoa S d,., on 0,, S wood Stoma Shed
D Sidq: a ofSgmtm Dl wlodo a
D Reommmetde f
DReem! aofs"m
()SttippwSolddhglm• ()gobgo.m bymofexkdm mf
nU dehhw0 hedlspemd ofae
Lomdmofra lky
1 dedaraaWs pemltlmofpwjmy tiatew rmemms loch waftieed am n mdamadl w#mhadofaqlmwledVwWadkf.]mdwmW6naor6lwamw(a)
wLhojMe fhrdeahlwnoostimAofmr/tl/ym�mddfbrpMeotimmdw�bLpG—.Lf126e,Sedim1.
Applisafs Sitmma: [�YGI�/I� Q.C;�l.tt/�o r—Bnu[13de: 5--Z3-6S=
Afpwad ar Dace:
aaaaiq Omdai (w dampen)
Zaniog Disltic
HWwW District ❑ Ya ❑ No
Wala It m Pmoewlm Diwlw:
❑Yes ❑No
Flood PleEn Zaem 0 Yes ❑ No
w'dhin 100 R of Wedaoda:
❑ Ya ❑ No
3A]
__MAY.24.2006-10:1EP^" NO. 697—P 2
MAY, 4,1UU6 1U.16A1 WF Y0. 67
5� r 8
gip" ""� ""A"""�'IMPO.RTANT DOCUMENT
4:ert,3ffcate of` lame Resistance
Ec1eymriON ISSUID By
It U s Date at shipment
NUNeek aIR �IF�'• 05N604
EVANSVILLE, INDIANA 47725 Tent Iddhflffcadan
MIA MANUFACTURERS OF THE FINISHED OW W4
6 TENT PRODUCTS UNBCRISID HEREIN
This is to certify that the Materials described have been flame-retardant treated
(or are Inherently noninflammable) and were supplied to;
76900
BARNSTABLE COUNTY CORRECTIONAL
6000 SHERIFF'S PLACE
BOURNE MA02502
Certitication is hereby made that:
The articles described on this Cartlfleata have been treated with a flame�retardant approved
chemical and that the application of said chemical was done in conformance with Calltornla
Fire Marshal Code. All fabric has been tested and passes NFPA 7D1-99. CPA184, ULC 109.
SoHai a romtmiq
OcecripliM of Ihm urlilied:
nxsT• Tov �ou�ua wlpr,vwrl.
Flame Retardant Process Used Will Not Be Removed By
washing And Is Effective For Thelife Of The Fabric
b'd OEZB-cLE-BOS.-Y-e JJoea %LErTT 90 60 RWW
of ►
TOWN OFYARMOUTH Building Department
BUILDING
(508) 398-2231 ext.261
®
PERMIT NO - 6-05-1338
ISSUE DATE '-
-
PROPOSED
-
PERMIT
5/18/2005
USE _ _ _ .:
APPLICANT ;Chase Canopy
- - - - - - - -
- - - - - - - - -
JOB WEATHER CARD
PERMITTO Misc.ftents '
AT (LOCATION)
001088RAY FARM RD N (+96)
ZONING DISTRIC R-40
Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1060.121
BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-d
LOT SIZE
REMARKS
erect three temp. tents- duration
AREA (SO FT) EST COST ($ $0.1
OWNER Town of Yarmouth
ADDRESS 11146 Route 28
South Yarmouth I MA 102664
J PERMIT FEE ($) $0.00
BUILDING DEPT BY
CONTRACTOR
LICENSE 0
POS 46
Mattapoisett MA 02739
5087582055
INSPECTION RECORD FIELD COPY
owes Ur o*
of vqR� SHEDS LESS THAN 150 SO. FT. SHALL j -
D BE PLACED A MINIMUM OF 30 FEET
' O( _ y FROM THE FRONT LOT LINE AND A r«t Gua e�rd
,e d' MINIMUM OF 6 FEET FROM SIDES AND dmowlhaHam
REAR LOT LINES. ibmawL
SS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth BaiNiog Department
MAY 1 S 2005 1146 Route 28
South Yarmouth, MA 02664
By (508) 39��887-2231 Ext. 261
CON3'PRUCRONAMRM. _ i (�8 Ali-' f , /�Gi . �%O • . i�G fWC0715� `O f t
ASSESSOR'S INFORMATION:
_ Map: Parcel:OWNPR:ID+-J-1 Oio 461�o&4
cmzmcToit: CAe-se .02731 sY- �sb'-Zos's
/ NAIL i MAJIM0 ADDRESS L—j
CR�d�I ❑Ca®ecid Pit Cast ofCmtroctkaf
Hme Impovemcat Cmftzw Lie. A Cmshatim Sapavisof Lia.
Watlimm's Compeneaboa avmmcc (check one)
0 I am rho hmeowm 0 I am the wok popiM 0 1 have Wooer's Cmpeavmim huamoe
hewn CampmyName: WadmesCaarp.Pelicy/
� -3 woltx ro sa reaFosnnn
VTa (raa Rdmd.mCadlRademmand) '' qq� �_
Dmatkw / / / WoadSta slo
0 si&w s dsgp 4� eO D Replumeti wmdowc R
0 RaOscomwtdoas: s
D Rsmae s dsgr
() SbEPhO aldlhhW=l ()suing vvr -Ivy—da>oNdyrod
Ile dehda will be d sp=W dt
Lmad atFaadhy
1 dmlwa awdrpmaRim ofpwjmy%dtha ddamenh' i cod aWmtwwd todwhedd
ill hejmta fbr dedal arrwomEund mylmowledga aad twlid IuadwOod Qd my Sbeauwsp)
w my�'cesre sod tar t�� mds M.Q.L lA Ms, saetiw 1.
Applicam't Sissew -op, Tar-P Dale S / "P— o S
owma Rl�.a.. (armime.) D.tc Jam` l P ' D S�
App—ed Dr.
BuddMOmdd (Q de:p-)
Z,,i,R —L
IG.vtoncelDaftict ❑ Yea ❑ No FloodPloaZmc ❑ Yes ❑ No
Water Rewom Ptotectiaa Dishict Within too a Of Wcdmdm
❑ Yea ❑ No 0 Yes ❑ No
Vol
gtt5 15 4, %ac1�of_ �Jr l f-u nr( Pres�rt/��oa Ccssoc .
4-1-4 Q. wtv, l �e-e p F�s�t vim(
butbz's
ame
of M
this is a
uner lot,
rite in name
street.
SHEDS LESS THAN 150 SO. FT. SHALL
BE PLACED A MINIMUM OF 30 FEET
FROM THE FRONT LOT LINE AND A
PLOT PLAN MINIMUM OF 6 FEET FROM SIDES AND
REAR LOT LINES.
FOR LOT M
Additicne vr� �hedof lines - or accessory b�+�9
------------------
arbgs disposal (cesspool)
Well no
I(]at................ft. rear)
(lot..................it. fxontaw)
(NAME OF STREET)
information
Abe
Mai
Lot
Tf
call
Mr
T Ti
a ott
str
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0
REGISTERED �4ar.•'r
APPLICATION
NUMBER
F�
IMPORTANT DOCUMENTS �It�nn�n�nLnur��rrr�nurm„uur�
Of fYamit
ISSUED BY
INDUSTW 3I4
Ca
EVANSVILLE, INDIANA 47711
�Pgitl�tP
MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been
(or are inherently noninflammable) and were supplied to:
CHASE CANOPY COMPANY
4 NICKY'S LANE
P O BOX 46
MATrAPOISETTE MA 027390406
Certification is hereby made that:
The articles described on this Certificate have been treated
chemical and that the application of said chemical was done in
Marshal Code, equal to exceeds NFPA 7ol, CPAI 84, ULC 109.
The method of the FR chemical application is:
Serial 11: 8140200
CENT END 40W X 20 Ho vL w w
W
Date of�anru�98ure
Order Number
E181585 N
m
D
flame-retardant treater{
7C
v
z
-c
with a flame-retardant approvec w
conformance with California Fire
riame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
' Signed:$
Name of Appfrcetor of Flame Resistenf Fintsh TENT DEPARTMENT—ANCHnw Indnuc
INC.
J�[PrJ`—irJCPcf m
REGISTERED
APPLICATION
NUMBER
F140.01
IMPORTANT DOCUMENT
irate of jr1atu e
ISSUED BY
INDU37A SING®
EVANSVILLE, INDIANA 47711
MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been
(or are inherently noninflammable) and were supplied to:
�nnsu�u�crrnrsLnrsua-
m
A
Y \
Y
CHASE CANOPY COMPANY
4 NICKY'S LANE
P O BOX 46
MATTAPOISETTE MA 027390406
Certification is hereby made that:
The articles described on this Certificate have been treated
chemical and that the application of said chemical was done in
Marshal Code, equal to exceeds NFPA 7019 CPAI 84, ULC 109.
The method of the FR chemical application is:
vc IIFKJVII ul IIOIII Gul Ull"u;
8140300
CENT END 40W X 20 LO VL W W
Date of 6 w
�Ln
Order
2'x
iR
m
n
flame-retardai o
TL
6L {L Ir a
V" <
✓ i
with a flame-retardant
conformance with --Cali
(0001)
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
Y
m
00
CD
w
lfl
m
w
0
N
Signed: /.Sery� ro
TENT DEPARTMENT —ANCHOR INDUSTRIES IN m
REGISTERED
APPLICATION
NUMBER
F140.1
1.
IMPORTANT DOCUMENT
rJ�rrsrs�nl�uusuuu�n�nr n
m
N
Prtifiratt of if lame
ISSUED BY
,YNM M1111r.
c EVANSVILLE, INDIANA 47711
ikagtanve
MANUFACTURERS OF THE FINISHED
TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treatedo
(or are inherently noninflammable) and were supplied to: c �U.0c
Date of Manufacture
05/26/00
w
CHASE CANOPY COMPANY
4 NICKYS LANE
POBOX46
MATTAPOISETTE MA 027390406
Certification is hereby made that:
The articles describedon this Certificate have been treated
chemical and that the application of said chemical was done in
Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109.
The method of the FR chemical application is:
Jenai P,
8140300(1)
Description of item certified:
CENT END 40W X 20 L0 VL W W
Flame Retardant Process Used Will Not
Washing And Is Effective For The Life
SNYDER MFG NEW PHILADELPHIA,OH Signed;
Name of Applicator of Flame Resielant Finish
Order Number 0
318211
m
10
�n
m
w
m
m
With a flame-retardant approvedw
conformance with California Fire
Be Removed By
Of The Fabric o
N
DEPARTMENT—ANCHDR INDUSTRIES INC.
PrJ�cP[P[PCP[PLP[PLPr_P[P[PcPcP[P[P[P[P[P[P[P[PfJ�[P[P[JC m
04/19/05
13:51 CHASE CANOPY COMPANY a 15083990936
P.O. BOX 46
MATfAPOISETT, MA 02739
TELEPHONE: 508.758.2055
FAX:508-758.2083
E-MAIL. Info@chasecanopy.com
WEBSITE: www,chaswanopy.com
Taylor Preservation Assoc
C/O Lynn MacIntyre
P.O. Box 66
Yarmouthport, MA 0267S
ATTN. LYNN MACINTYRE
Phone: 508-395-9407
Salesperson: Andrew Chase
Event Time
Start 06/05/05
End 06/05/05
No.372 D01
Page: 1
Date: 04/19/05
Revised Contract: 985208 3
Work Order: 804399
Acct ID: TPA
Type: CHARITY
Site:
108 BRAY FARM/NORTH
YARMOUTHPORT
setup Time Removal
06/03/05 06/06/05
06/03/05 06/06/05
Thank You for your order. The equipment listed below has been
reserved for your event.
Time
•INPORTANT: FINAL changes to Your order must be received before
05/29/2005. We cannot guarantee additions or changes
after that. Any changes made after 05/29/2005 will incur
a $25 fee per occurrence,
QTY COLOR DESCRIPTION
----- ----RETAIL STANDARD EXTENDED
----- ---- -- ______------ ______
-----------
1 PK/WH 4OX60 ANCHOR OLD R&P TENT -----
1,354.00 700.00 $700.00
General Contract Notes
PINK & WHITE TENT
Thank you for your order
Payment Terms: 3 DAYS PRIOR TO DELIVERY
135400 10.1C(579)
Subtotal
TOTAL
Rec'd To Date
BALANCE
700.00
$700.00
-700.00
$0 00
TOWN OF YARMOUTH
JUN 0 3 2005
By N
APPLICATION FOR PERMIT TO DO PLUMBING
(OFFICE USE ONLY)
By /l C A Fee: $ Q
PERMIT NO. P-O'-J --I55
nat.3 9n O ti
Building Owner's
AT. Location /off [317 ame
New ❑
Plans Submitted
Renovation ILY
Type of Occupancyc.
Replacement ❑
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SUB-BSMT.
BASEMENT
1 ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE)
Installing Company Name D " • B {l,i I/�_ _
Address i;7oV % (- /
Check One:
❑ Corp.
❑ Partn
�• �f'}LAf a V;LqN'/ irm/Company
Business Telephone p ��� Name of Licensed Plumber n/ v 45 nu V (,oSI `
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes ❑ No ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check on Owner ❑ Agent ❑
Signature olOwnerorOwner's Agent
hereby certify that all of the details and information I have submitted
�L
�/"tn
� -Sigrfdfure of Licensed
(or entered) In above application are true and accurate to the best of
Plumber
my knowledge and that all plumbing work and installations performed
under Permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and
License Number
Chapter 142 of the General Laws.
Type: Master ❑ Journeyman'
or r TOWN OFYARMOUTH Building Department BUILDING
(508) 398.2231 ext.261
PERMIT NO •-FB-04-1118 - - - - - PERMIT
ISSUE DATE - 4/1=004 - PROPOSED USE ' PERMIT
1
APPLICANT 'ChassCanopy JOB WEATHER CARD
PERMITTO Misc.ftent '
AT (LOCATION) 100096BRAY FARM RD N (-108) ZONING DISTRIC R-40 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 151.24 BUILDINGISTOBE: CONSTTYPEF—] USEGROUP=
LOT SIZE
REMARKS
AREA (SO Fri
OWNER C
ADDRESS R
temp tent: duration 5/28/04 - 5/30M4
EST COST ($ I$700.00 PERMIT FEE ($)
BUILDING DEPT BY
CONTRACTOR
LICENSE 0
POB 46
Mattapoisett MA 02739
8006492055
INSPECTION RECORD FIELD COPY
T�F�A
L
mhs Rom
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261
CONSTRUCTIONADDRESS: /OD /BPAy F?f.O4af K n A )6n Y/`f��'f Ocrjj/�Oa�T
ASSESSOR'S INFORMATION:
P. / $ / Parcel: Zq
Home /�.bPPRESENT ADDRESS iq.. r
CONTRACTOR0FfA� ! _"RAYf %Po . 'fix 46 TT Q'ICc oL 13 g 800 - G ,ram, �c
NAME MAIUNp ADDRESS 1 TELA
0 Resklentiel - 0 commercial Est Cost of Cautrueaon S ' 0— . O O
Home Improvement Contractor I1a r Consort" -m Supervise Ile. M
Worlmtan's Campansdan hmeam,,, (d,& tor)
❑ 1 gaga the homeowner 0 1 an the sole proprietor 0 1 have Worker's Co mpamlim basset,,,
Ira once Company Name: Worker's Camp. PolicyN
WORK TO BE PERFORMED
iaa (Fire ReW6stCalifioleamehed)
DoradonMay 1 _M� 0 Wood Stove Sled
❑ Siding: a afSquuea D RatAstewwwan, wvrdow, r
0 Rep6asent door, r
❑ Rotoot / ofSgsaru
() Sopping old Angles- 0gains over syM ofeaimtag mat, )'AAFPR0VED 0
erhe debris will be disposed ofar Rh'DUrN COr.i';l/7TRr�.,
I declare
under
penalties
of jM dad
tmemnsm, eoohuedre hve ad omers the besl ofary knowlde and bchet IoWrstand thsay yho aaswq(s) iusfor nof e
my lireme and for prose siio s under MO.L Ch. 268, Saxon 1.
Applicant's Signore: ///. �, �"l�e. / Qr3 Date,
Oaoba signature (a arochment) 1 3f$S—Q r% ...`.
Approval By: pte,
Bnddtrig Ot6cr1 (a designee)deee)
L Zoning District: 12,10
to Hisrical District: AI Yes ❑ No Flood Plain Zone: (�i� M ❑ No
Water Rsotace Prot, ection District: Within 100 R. of Wetlands:
❑ Yea KNo , 71 Ys 0 No
C�E.rttftraft laf Jfilttm� � i tttrtrE
REGISTERED o- ,of5/Poo ISSUED BY
APPLICATION INDUSTRIES INC.
NUMBER ANCHOR
� �Data of Manufacture
T =7t EVANSVILLE, INDIANA 47711
F7002 �•y °/RE Mp�p'' MANUFACTURERS OF THE FINISHED
f kEir`a TENT PRODUCTS DESCRIBED HEREIN T2012 4/1/89
This Is to certify that the materials described have been flame-retardant treated (or are
Inherently noninflammable) and were supplied to:
NAME: Chase Canopy Co.
CITY Mattapoisett STATE
Certification is hereby made MA
that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California
Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84 Part 3.5.9 of CCC-C-428E (also
Method Of application: IMPREGNATED
claaaified by UL Flammability only 3541)
Type, color and weight of canvas/vinyl: 12 Oz. Gala Pink/White
Description of Item certifled: 40 x 120 6pc. Sq. End
Party
Tent
Flame Retardant Process Used
Washing And Is
Will
Not Be
Removed By
Effective For
The
Life Of
The Fabric
Granites
Name of Applicator of Flame Resistant Finish
Graniteville, SC
Signed:
-,�g�.<..a,
P� • /�y��.�2
TENT DEPARTMENT —ANCHOR INDUSTRIES INC.
Louis R. Brown
To"n of Yarmouth
N ' COPY
�-0,(-77o shki
APPLICANT DAT01
_JaQmmeXCil
PERMIT TOrepR AOORE55 T'"MIT NO. B�-Ol— �O
—_TQ
INO.1a ��STORY I$TREETI CS`,IpROp NUMBER OF OEZONING
CROSS STREETDISTRICT0 AND
O
O LOT ICR0SS STFEETI
m BUILDING IS TO BE BLOCK LOT
0 —FT. WIDE BY —SIZE
Z — FT. LONG BY _
f TO TYPE
A USE GROUP FT. IN HEIG � HT AND SHALL CONFORM IN
'T� BASEMENT CONSTRUCTION
REMARKS: WALLS OR FOUNDATION
' u ITYPEI
BUILDINGRMIT
r PE
VOLUME
(CUBIC/SQUARE FEET(
OWNER T yrp Q Ya ESTIMATED COST $
ADDRESS I0B B a Fa R PERMIT $
PERMIT
BUILDING p
BV
/r
OrCORD
Once Use Only
P.m.kN -13lI V-0-
I=S tvlc-
Permit expires 6 months from
issue date.
EXPRESS BUILDING PERMIT APPLLBy__]
TOWN OF YARMOUTH Yarmouth BuildingDepartment2001
1146 Route 28
South Yarmouth, MA 02664
1� (508) 398-2231 Ext. 261
CONSTRUCTION ADDRESS: @ & 4y h A_ 2 M i a &z
ASSESSOR'S INFORMATION:
Map: Parcel: o"
OWNER: Sn tt n_'���2�.�t� i i{
NA MI; tPRESENT ADDRESS TEL. M
CONTRACTOR:
tiME,prttig�
NAMAILING ADDRESS TEL.N
❑Residential ommercial Est. Cost ofConstruction S_/G..300�-
Home Improvement Contractor Lio. N Construction Supervisor Lic. N r IR p V9 3.5'1
Workman's Compensation InsurgpeE (check one)
❑ 1 am the homeowner - I am the sole proprietor ❑ 1 have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp. PolicyN
WO K TO BE PERFORMED
❑ Tent (Fire Retardant Ccttificate attached)
Duration
❑ Siding: 4 ofSquams
❑ Re acemem windows: N Cl Replacementdoors:
N
tY to -roof. NofSquares Z-
)Vkrtping old shingles- Ogoing over layers ofexisting roof
'The debris will be disposed ofat: yy�,(i �s 0 J LJTLNJ / 6S4 l aA. , � y 14 Atr'i1r-
I declare under penalties of perjury that the statements herein contained are we and correct to the best of my knowledge and belief 1 understood that airy false anssver(s)
will bejust cause fm denial or revocation of my license and for prosecution under M.G.L Cla 268, Section 1.
Applicam'3 Sigtamre:
Owners Signature (or i
Approved By: Date:
Building Official (m designee)
Historical District: Al
Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 R of Wetlands:
❑ Yes ❑ No ❑ Yes ❑ No
3/01
ZOO/
Ot /YAenw,.7r%1
ll4CP �001� �
YAer%A.0, la , M.4.
Oz6(e4/
APPROVED
YARMOUTH COM
OKHRD MITTEE
= AA.- w�:Ti,wG To �gqV
AppA00A-L >~'�0„1 O lcl K, t s g t7 LwOuJ / -to
o b-C-a ,14 ct (ov a (ck III ; �e e cT $ate
Fr'p�ajjCen.��T -108 `arcs s rc4R1w�
�ccek I lie.` ft-0 Fcl C0AcSZ.S � 04 -�
J� `e Re.M1tduwL
0-1p T�C F-XLI; IvvI � cgbA2cY1Q j g4lAjd!Sl tZ.e�a�
04 A+�y 060A,4; o K d°cfr/ 1-4D c �t&q ;�do� 60. "Cu
f�A� - / r 1ncSi40A 10F{ OC- K-PV I� -cj av r(a1.:..
S11� �IrS �L grQc�+e � ��ewvoµ,. 3cLec`/ p�+ GJe2
�^ V
yacJnw� sP���'t��'-ones,
/�arnPT�ay (b..rReer i c �S
=�R - BUILDING
o TOWN OF YARMOUTH ELECTRICAL
A C dk � I146 ROUTE 28 SOUTH YAR.\(OUTH MASSACHCSETTS 026G'i GAS
"'Wllllll`sM 0 "Telephone (508) 398-2231 PLUMBING
diFwy
N
f ,.t �� BUILDING DEPARTbtENT �/
3/- APPLICATION TO ERECT AND MAINTAIN SIGN (J� I
DATE
TO THE SIGN INSPECTOR: UNDER SECTION 303 OF THE YARMOUTH By -LAWS, THE UNDERSIGNED
HEREBY APPLIES FOR A SIGN PERMIT ACCORDING TO THE FOLLOWING IAFORHATION:
BUSINESS NAME FPfr-vvl TEL: 3KS- 61 la
LOCATION/ADDRESS 1 n SC 'C-� Q.AY FAQ )nn P 11 . &
ZONING DISTRICT L.B.— G.B. IND. RES. ,, BIST. DIST._t,�
BUSINESS OWNERS NAME/ADDRESS few RJ O 1= Y/}2w\OU'jp� TEL:
OWNER OF RECORD OF BUILDINGDRESS
SIGN BUILDER 2fj2Lfi fS SH-L-
t2.tr ADDRESS (C9 (V 59pty F-J1-{:)y;.\ 2„1)
TYPE OF CONSTRUCTION MATERIAL(S) WIDO LIGHTING TYPE
FREE STANDING l` ATTACHED TEMPORARY PERMANENT
DIAGRAM OF LOT AND SIGN WITH DI.MENNSIONS AND SET -BACKS FROM PROPERTY LINE. SHOWN
LETTERING AND ADVERTISING ON SIGN. FOR ATTACHED SIGNS SHOW LOCATION ON FACE OF
BUILDING AND RUNNING FOOTAGE OF PORTION OF FRO E OCCUP
T
i
V I I Ifl�Nll i t�
InI"I: V, 10) 1flll: I'll C:111
G IID BY BUSINESS.
d
I HEREBY AGREE TO CONFORM TO THE ZONING BY-LAWS, SECTION 303 OF TEE TOWN OF YARMOUTH
REGARDING THE ABOVE SIGN CONSTRUCTION. I FURTHER AGREE TEAT THIS SIGN WILL NOT BE
ALTERED, ADDED TO, OR CHANGED IN ANY WAY UNTIL A NEW PERMIT HAS BEEN GRANTED. THE
NUMBER OF THIS PERMIT WILL BE AFFIXED TO THE SICK 72M NO LESS MAN 3/4" N
ALL PERMITS SUBJECT TO APPROVAL OF THE SIGN INSPEL�OR. `
r
APPROVAL BY n� M DATE fair^ FEE /!� G �BER_
3T
APPROVED
YA h UTH COMMITTEE
t�• 40KHRO ASLI
4
-WELCOME
{T�i���J�Yn1ju(III� W
¢� D I.Al.1I1Y� O �1]LJl3 Imo, \!L]Ll UY�L.FI]YVU „ RG¢/+„NO
Tummc
— IN Ce4MATeN TO F.F
� � WVLwANNJ
MAR• BAACR{O¢BN 1❑ '� T i!W{W �1! BL/KR LTL.
vF¢„1 4YSY � � i ns r T1 W
a 1
P2EA Fe2 T.WN
F•RfA II bEFy bPEN Ta }Np�JBCIC I•ND NiS�nt.CAl.
t10v4tV Re S.
I
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ail AOPw. L� � I
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d
.inter. uow
ser. 4 e - - 6
e 1
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\ tea•: - -"-
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_✓•u r. L0. — — J
A Vv.. IeFf
t/ Artlsf
Se r 1Jt f 1
i
wnu'm'
e rl
Old Kins s Highway Regional Historic District Committee
M the Town of Yarmouth for a 40Z9,
CERTIFICATE OF APPROPRIATENESS
Application is hereby mad•in Indicant, for the Issuance of a CONliule Of Appropriateness under Section 6 Of Chepntra]U.
AM and Resolved of Masuchueaaa. 1970. for proposed work as E ilium bed be. and on piano. EMWinga or Photographs
Photographs
accompanying this application tar. i[1 g
w
CHECK CATEGORIES THAT APPLY: -T
1. Extoller Building Construction, 0 New Building ClAddition Calibration
tracer. Was of building: O Houu OGaral. GComm•miM GOtner
2. Exterior Painting: 0 n- -0
0. signs or Biilboared. ONew sign Cavidn9lgn O Repenting existing sign n- N
4.51uclub:0Fenc• OWII OFlagpab 001he1 �.
(Pious mad anon aide for edpbnstlon and rpuiremenu(. pap 19 r 199a
TYPE OR PRINT LEGIBLY DATE
Bray Fan
ADDRESS OF PROPOSED WORIc 30B Bray Fan Rd. Worth, YP ASSESSORSMAPNO. 134
OWNER Tore of Yarmbath ASSESSORSLOTNO. T-7
HOME ADDRESS 11/6 Route 28, south Yarmouth 02666 TEL NO 398-2231
FULL NAMES AND ADOR ESSES OF ABUTTING OWNERS. Include nome of adjacent pmpenY amount acmes airy public
street or way. (Aftj additional Shut it naradeary).
See attached.
AGENT OR CONTRACTOR Tom Bharat TEL NO 385-6499
ADDRESS 109 Bray Farm Rd. Borthr YP
DETAILED DESCRIPTION OF PROPOSED WORK: Give MI pNiculan at work to be done (see No. S.Other eidel. including
matemle to be used. it apeeilicali n. do not accompany Items, In tna cue of signs, give locations of hart g signs and
proposed locations Of new signs. (Attach additional sheet it necaMary),
Bray Farm freestanding entrance sign
Signed ,e^ar-Cpnu.ct -Aydin
sew er...n br C w-werr r.
Received by H.O.C.
Date � The CMtlliaate N hereby Date
Time ^k I{
BY �' r I�I9M-n1J CROVEO
O IMPORTANT: it Certificates is approved. approval is ublect to tn• 10 day Spp�Hrd6hEtliSEE
provaed in the Act. WKHRD
]1n:crcvec. ❑ Pleaserelurnto: Yarmouth Hialenc District Commlcep
Town Nall. lull NO. 23. Scum Yarmouth. Mast 02664
TOWN OFYARMOUTH Building Department BUILDING
r (508) 1
PERMIT NO & g/076 - - PERMIT
ISSUE DATE 5/29/03 PROF osED USE
APPLICANT TOWN OFYARMOUTH JOB WEATHER CARD
-- - - - - ---
ADDRESS '1146 Routeto 28 PERMIT TO ;---MiscRen-t '
AT (LOCATION) 100108BRAY FARM RD N ZONING DISTRICT R-40
SUBDIVISION MAP LOT BLOC 151.24 BUILDING IS TO BE USE GROUP
LOT SIZE 0 CONST TYPE CONTR'S
LICENSE 0
40 x 40 tent - two pieces, 20 foot middle tent: duration 5/29/03-06/02103.
REMARK CONTR'S NAM
AREA (SO Ff) EST COST ($ $600.00 PERMIT FEE ($)
OWNE TOWN OF YARMOUTH
ADDRESS 11146Route28 BUILDING DEPT BY
INSPECTION RECORD FIELD COPY
R�d �ECE'JEI r tI D
S Pcxn
ILC Permi apves 6 momhs from
h W issue date.
V B 7f,
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508�) 398-22331 Ext. 2661 TIC
CONSTRUCTION ADDRESS: r r�+-'1� 'v1 • • \ 1 \VCR � ""'c `\� 1 \%_1l.( , �-'n l J
ASSESSOR'S INFORMATION:
Map: / Parcel:
OWNER: � twit') "-/kjzKC" zt�
NAME
� �9 PRESENT
r.A1313 ESS TEL. #
CONTRACTOR: ( � CWOPLj 1 MWMAPOOM 1 \ 1TT
NAME MAILING ADDRESS TELA �r�j
esidentfal El Commercial Est COSt of Construction $ 60,�am 'y f�
Home provement Contractor Lic. # Construction Supervisor Lia #
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ 1 am the sole proprietor ❑ 1 have Worker's Compensation Insurance 1
Insurance Company Name: Worker's Comp. Policy# () l
kem (Fire Retardant Certificate attached) WORK TO BE PERFORMED YARMOU NRCOIfDI `J
Duration S 3 - (p/.�. Q 3 Shed QKF176 �E(5i )
El Siding: # of Squares
❑ Replacement windows:# 70Y vo —. PPleee's ❑ Replacement doors: #
❑Re -roof Squares �jQv7 m%'e.Z7L
() Stripping old shingles- () going over_layers ofeaisting roof
°The debris will be disposed ofat
Location of Facility
I declare under penalties of perjury at the Smtements herein cortpined are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
1l bejust cause foA'or rev �'on afmy liceeg nu Hp for prTutiot}ur '>, L. Ch. 2T S,S nI.��a blicant's Signatu¢` Date:�ers Signature (nl) Date:
Approved By: — Date:
Building Official (or designee)
Zoning District: f"70
Historical District: Yes -f\No Flood Plain Zone: ❑ Yes jI'No
Water Resource Protection District: Within 00 R of Wetlands: / —
❑ Yes
Yes ❑ No
3/01
rc
(nertiftrate of 31ame Resistance
REGISTERED ISSUED BY
APPLICATION ANCHOR INDUSTRIES INC.
NUMBER EVANSVILLE, INDIANA 47711
MANUFACTURERS OF THE FINISHED
P7002 TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been
inherently noninflammable) and were supplied to:
ChaseCana Co
Data of Manufacture
T2012 4/1/89
flame-retardant treated (or are
NAME: Py
CITY Mattapoisett STATE
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 Marshall Code, equal to or exceeds NFPA 701, CPAI 84 Part 3.5.9 of ccC-C-428E (also
Method of application: iro'sECNATa^ rlaasif"ed by nT t - - hility Only M41)
Type, color and weight of cenvaslylrryl: 12 oz. Gala Green/White
Description of item conilled: 40 x 40 2pc. Sq. End Party Tent
Flame Retardant Process Used Will NOT Ise Hemoveu oy
Washing And Is Effective For The Life Of The
Fabric
,
m v — Signed:a�w AC• —""
in Nam s of ApppllBator of Flame Resblam Finish 7EN�E7A MENT—ANCHO INDUSTRI I�t �.
-i Craniteville, SC
Louie R. Brown
M
V)
N
Cneettftcate of Name lestotance
REGISTERED ISSUED By
APPLICATION ' ANCHOR INDUSTRIES INC. Data of Manufacture
NUMBER � EVANSVILLE, INDIANA 47711
MANUFACTURERS OF THE FINISHED
P TENT PRODUCTS DESCRIBED HEREIN T8381 9-8-88
This is to certify that the materials described have been flame-retardant treated (or are
Inherently noninflammable) and were supplied to:
NAME: CHASE CANOPY
CITY NETTAPOISETT STATE MA
Certlflcation 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 Marshall Code, equal to or exceeds NFPA 701, CPAI 84 VARTP3-.5;9OF CCC-C-428E
Method of application: IMPREGNATED (ALSO CLASSIFIED BY UL FLAMMABILITY ONLY
Type, color mM walght of eenraaNlnyl: 12 02. GALA GREEN AND WHITE
Deecripllon of IOam canlllaa: 201 MIDDLE FOR 40' TENT
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
ems o pp Ice ar a aura Raaletant Flnlsh Signed: ��O.a+.
T CNT DEPART E —ANCHOR INDUSTRIES 1 C.
GRANITEVILLE, BC I LOUIS BROWN
r
o. TOWN OFYARMOUTH Building Department BUILDING
® --- (508)398-2231 ext.261
PERMIT , FB26/2004 PERMIT
v L ISSUE DATE 4/2612004 ,PROPOSED USE - - ,
APPLICANT Tayl&BmyFam'Pr-eservation - - --- JOB WEATHER CARD
PERMITTO Demolish
AT (LOCATION) 100108BRAY FARM RD N I ZONING DISTRI R-40 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1151.24 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-d
LOT SIZE
CONTRACTOR
REMARKS demolish existing two story shed LICENSE
AREA (SO FT) EST COST ($
OWNER ITOWNOFYARMOUTH
ADDRESS 1146 Route 28
South Yarmouth I MA 102664
J PERMIT FEE ($)
BUILDING DEPT BY
INSPECTION RECORD FIELD COPY
omt. Use "y.
oF•Y� •3
Pam tj
O H
aaPves 6 months goad
`i �"""• a- ague Qen.
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(509) 398-2231 Ext. 261
C0N9MUCTR)N ADDRESS: /08 B44A- 6f}R[u r Ij A 0 . 0'P-�0417,f /QC'%
ASSESSOR'S WFORMATION:
ter: / 5'/ Parcel: zq
rEL.
U Itesidemal ❑ Commercial Ea. Cost of Cmatruction S C)
Harm, hnprovernerd Contractor I3c # Certstrtreim Superviaat Lao. #
Worlunan'a Comps sadont hsneeorcc (dw a roe) _
❑ 1 San the homeowner 0 1 am the Sole proprietor 0 1 have Worker's Compere ado, hmranoe
asurarke Company Name: Worker's Comp. Polity*
WORK TO BE PERFORMED
❑ ree (Fire ReWdae Catigealetatatbed)
D" r'tiO" wood Stove Shed liENdoGt7,Qj,V
❑Sit#og: #ofSgtrma
0 Repicrnaatdcors: # ORepl.ewneet wadowt#
ORo-roof #ofSgaves
0 SWTWa old s►igleas () loin eve h)sas ofsdstieg roof
vlhe debrisw,➢ he dim ofak Yaafo U-r71
I declare seder peaskien ofpajory dw the snadrrcan hoc rooiiaedare tree and worse to ere beg of ay keowledge and belie[ I radvebnd d t my Bha s,,,(a)
will be just sure far dread
Mor^revOcati n'of�m/Y imrc and for proseviion Ada MO.L Ch. 26#, Stories 1.
Applicaet's Signanrc �// - (; (J /I �O/J(,YiAO dim-F y -T�r-f R q
�—) Date:r / oO/L sf ZO p!f
Owsas Sigoatum (a atichmwt) .. .
Approved By: D, e.
Budtlutg OBmrl (a devgrx)
Zoning District: 7Q I
Historical District: �I Yes ❑ No Flood Plain Zone: ❑ Yea ❑ No
Writer Rcaotirce Pracction District: Within, If�B IL of Wetlands:
0 Yes PNo es 0 No
Application to
Old King's Highway Regional Historic District Committee
in the Town of Yarmouth for ayp
- '
CERTIFICATE FOR DEMOLITION OIVREMOVA,LL
Application is hereby made in triplicate, for the issuance of a Permit for Demolition or Removal of a building
or a structure or part thereof!, under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for
proposed work as described below and on plans, drawings or photographs accompanying this application for:
TYPE OR PRM LEGULY DATE f VIr ZoO.
ADDRESS OOFFPROPOSED W/OR'K9 V& r �./v ASSESSORSMAPNO.
OWNER /UW ✓r7J C ' (�IC�rw o ASSESSORS I.OT NO. � 9
HOME ADDRESS /� f1 2S, SOS 6zy_—,/1 oe TELEPHONE NO.
AGENT OR CONTRACTOR TELEPHONE NO v
ADDRESS �f
r
v
n
� o
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERS cO
DETAILED DESCRIPTION OF PROPOSED WORK: If building is to be removed, give new location. Snap shots > w<
showing all views of building must accompany application. Use additional sheet, ifnecessary.rt X
Dento%z5h qlve z sFar �hecP as 6Gtown roc
s�o
Note: If approval is granted fa relocation, a separate Certificate ofAppmpriateness is for location if within pt
the Old King's I-ligjtway Regional Historic District �y��✓�f ,/l vl
Si
on t
Space below line for Committee use only.
Received by OKHC f-
Date1?�� This Certificatte is h/e,rreby Date
Check A/� -E. t"' (-i� 41v i ,/ .LQ.
By
P` S - 6v.
APPROVED 13 IMPORTANT: If Certificate is approved, approval is subject to the 10 day appeal period
provided in the Act
DISAPPROVED O Please retina to: Yarmouth OKHC District Cowuittee
Yarmouth Towa Hall, 1146 Route 28, S. Yarmouth, MA 02664
;
� f� :��«
. 41
ME! 71 -,Jl
�®`��
:
���
�
,i
--� --------rron ----�-i
l TOWN OF DENNIS
� CREEK
(J
EN
GARD
� ayq
I �
1
---�J � nu•c fo�warrw�wrx ,�'� � 1 � �'
i-�
I a sae
p A.
NOCKANO
t r W6K
OEOK
xAe o,
OWE
!10• „-_ y� J l/ llt MAC; ��
Lo
�.
JB LLII
116 m
J3 ACO
0
ly,, • n O ,b �+N_ � ..
of TOWN OFYARMOUTH Building Department BUILDING
- - - - (508)398-2231 ext.261
PERMIT NO 6-=00 - PERMIT
ISSUE DATE ; - 9Y18/2004 PROPOSED USE '
APPLICANT ;Taylor - - Bray Frain Ores: Assoc. - - - - -- - - -' JOB WEATHER CARD
--- -- - - - - - --- -- - --
PERMIT TO Accessory Structu-re
AT (LOCATION) 00096BRAY FARM RD N (+108) ZONING DISTRIC R-40 Bldg. Type: Resitlential
SUBDIVISION MAP LOT BLOCK 151.106 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-4
LOT SIZE
REMARKS construct four accessory structures for livestock 8 storage
AREA (SO FT) EST COST ($ $4,000.00 PERMIT FEE ($)
OWNER Town of Yarmouth BUILDING DEPT BY
ADDRESS 1146 Routa 28
5outh Yarmouth I MA 102664
INSPECTION RECORD FIELD COPY
' 'onee Ur ony
oF.vgk SHEDS LESS THAN 150 S0. FT SHALL IwmnaS �' V31'
BE PLACED A MINIMUM OF 30 FEET
FROM THE FRONT LOT LINE AND A Fa S�
O 'C•) MINIMUM OF 6 FEET FROM SIDES AND 'P.mirexpbm6moatbsfrom'
REAR LOT LINES. I=ed9&
-.EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
SAP Z004 C� 1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Fact. 261
CONS-IRI M14ADDRESS: f �08 �Y F�4fes�f �D • �o • � Y��� u7bF�"i�J—
Ass&sSOR•s IIwORMATION:
Mar: /5-/ Parcel: 104
G
❑Reid ❑cmlmaew /4prrec,11WX-� Per c�oec oos ��f coo
Fiume hWwvcmmt coatmcter tde. a ematratjmsatrlvisorI.ic.#Ila /J
WohmWsCmwpensabmlati,a (check me)
D Iam the hawww 01 am 0e sole puprietar 0 l have worker's ComVensafiGn
campm➢Name Wortets Comp. Pohq#
WORKTO BE PERFORMED
❑ Ten (rmRaf+danc.cfiuessarb*0
Diiifd- wood Move sbea
D Sidiog: M ofSgo.es 0 RePb,= en wmdowe d
o Replw m t doors: d
oReqooC .l orsa�
sa _. oromtiosraac
()tripping ald ehoB+ee () BBB _ ,
-no debris win be
� /wifibejuvt a
V Apph .t•s Sigm
sbaemm I i aaneimd,n mkdame tOdObetofmylmowledgomdbdief. tmderdmd&dmyb*owww(s)
tiny sad for mom bCOL CL 262, S-etion1.
j Dslc
bare:
"p"°"`d By-* aaaiegofam (m deu®ee)
/Zming
Historical District G' Yes ❑ No Flood PI—Zme: ❑ Yes 6_�ko
Water Resource Protechm Distict Within tog R of Wetlmdx
❑ Yes 0 No D' Yes 0 No
101
buttor's
ame
of #
this is a
=ner lot,
rite in name
`_ street.
a
L
a
SHEDS LESS THAN 150 SQ. FT. SHALL
UM OF 30 FEET
PLOT PLAN FROM HE RONTrLOT LANE AND A
MINIMUM OF 6 FEET FROM SIDES AND
REAR LO.T LINES.
FOR LOT #
Indicate location Of garage or accessory building
Additions with dashed lines --------- .........
Sewerage disposal (cesspool)
Well
I(lot................ft. rear)
SIDE YARD
I
i
REAR YARD
SIDE YARD
i
SET HACK
(lot..................ft. frontage)
Abt
Mai
Lot
P.,
1
(NAME
OF STREET)
InforInSupplied
gL
`A
1-4
FIELD COPY
BUILDING N�
2oVm of Yarmouth
PERMIT 5'01- cl$s- b b& fq
b
DATE June 26. 2001 PERMIT NO. B-K- 985
APPLICANT ToI of Yarmnnrh/Dnn TAr]' tyre_ ADDRESS 103 Bray Farm Road Y P 0267
INO.1 ISTREETI (CONTR'5 LICENSE)
PERMIT TO dwmnN ti nn NUMBER OF
(_) STORY DWELLING UNITS
ITYPE OF IMPROVEMENT) NO. (PROPOSED USE)
AT (LOCATION) ln8 Brny Fnrm Enna 4_p_ 07675 DONNINGISTRB 40
I NO.1 ISTREET)
a BETWEEN AND
m ICROSS STREET) (CROSS STREET)
m st
SUBDIVISION 1 In LOT TTrap p 136 SIZE
a
V
0 BUILDING IS TO BE FT WIDE BY FT LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
m
E TO TYPE USE GROUP K4 BASEMENT WALLS OR FOUNDATION
O (TYPE,
LL REMARKS: demolition BE frapad—graaa—hovss
AREA OR
VOLUME ESTIMATED COST
(CV BICISQUARE FEET)
FEEMIT $ NBC
ncIn u1 �� /
INSPECTION RECORD
ONE & TWO FAMILY ONLY - BUILDING PERMIT
o®0 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
— y Town of Yarmouth Building Department
1146 Route 28 • Yarmouth, NIA 02664 }492
Tel: (508) 398-2231 x261 • Fax: (508) 398-2365
OOfficee Use gOnly
Permit No. _t�f� OWN LW
Permit Fee $.56'
Deposit Rec'd. $ N (°,pate _
Net Due i.Q _
Planning Board Information
Plan Type
Endorsement Date
Recording Date
Plan No.
Other
Department Information:
Ma r r
Assessors JV
r
Ofd New
1.4 Property Dimensions:
LotArea(sf) Frontage(it) Lot Coverage
This Section for Office Use Only
Number: Date Issued:
pBuildingPermit
: ,S t p /
Buildin Official Date
Certificate of Occupancy
is is noty required
Section 1 - Site Information Use Group: R-4 Type: 5-B
1.1 Property Address: =1.2formation:
District Proposed Use
dTHPeP--r
1.3 Building Setbacks (I t)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
1.4 Water Supply (M.G.L. C. 40. 5 541
Public Private
1.5 Flood Zone Information: Comments:
Zone: C— BFE:
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Record:
eP �/+Rf2orrTtf
Name (I'mMailing Address
5
Signature%)p c K� Telephone
0 2001
,V
All,
RV
2.2 Authorized Agent:
/ 0 3 &e.+ Fi }fit ICD. K)o .
Name (print) Mailing Address
38S= P�fo7 Y�4n-•u ou774I-OZ r
Signature Telephone
Section 3 - Construction Services
3.1 Licensed Construction Supervisor.
Not Applicable
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor.
Company Name
Not Applicable'
Address
Signature Telephone
License Number
Expiration Date
lof2 OVER
Section 4 - Workers' Compensation Insurance Affidavit (M.G.L. c. 152 S 25C (6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failura
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes .......... No
Section 5 - Description of Proposed Work (check all applicable)
New Construction I No. of Bedrooms No. of Bathrooms
Existing Bldg. ❑ Repair(s) Cl Alterations ❑ I Addition ❑
Accessory Bldg. Type eA
Demolition r/
Other Specify:
Brief Description of Proposed Work:
EJ
Costs
- Estimated Construction
Estimated Cost (Dollars) to be
completed by permit applicant
Check Below
_
❑ Conservation -Commission Filing
(if applicable)
Old Kings Highway & Historical
Commission approval
(if applicable)
a
al
ng / Gasical
(HVAC)
tection
6. Total =(1+2+3+4+5)
7 Tolal Square Ft. (new houses&additions)
Section 7a - Owner Authorization -
Owner's Agent or Contractor Applies
To be Completed When
for Building Permit
, as owner of the subject property
to act on
hereby authorize
my behalf, in all matters relative to work authorized by this building permit application.
Signature of owner Date
Section 7b - Owner/Authorized Agent Declaration
/ ,/ c
I � /"L as Owner/A thorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge and belief.
/and penalties of perjury.
Signed under the pains
Print name /
Signature of Owner/Agent Date
9-15-99 2 of 2
SOTYA�
% BUILDING PERMIT APPLICATION SIGN
`J, or- �jg-eu-f
Applicant: YO fJ /"( O-Qr-)T YISE 4 6 ENT Building Permit No..
Address: to 3 6±9q 20`: Tel. No.: 3 —?Mate Filed: �' r D
Bldg. Site Location.108 �RA`/ r*Ri4 ieD, M.Map No.: Lot No.:
The following information outlines the procedural steps required to obtain a permit to build, alter, or add
to a structure within the Town of Yarmouth. The Building Department will determine compliance to the
following: (A) Zoning Requirements (B) Historical Districts (C) Flood Zones. The Building Department
will be responsible for assisting the applicant through the following departments:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: Determines Compliance of Water Availability. (applicant to obtain)
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type
of Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc.
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
for Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
----------------------------------------
The follouring Departments must sign off, in the respective order, prior to building inspector issuing the required
building permit:
TOWN OF YARMOUTH
BUILDING DEPARTMENT
OFF
1. WATER DEPARTMENT:
DATE:
N/A:
2. ENGINEERING DEPARTMENT:
DATE:
N/A:
3. CONSERVATION:
DATE:
N/A:
4. HEALTH DEPARTMENT:
DATE:
N/A:
INDUSTRIAL AND/OR COMMERCIAL PERMITS
5. WIRING INSPECTOR:
DATE:
N./a
6. PLUMBING INSPECTOR:
DATE:
N/A:
7. FIRE DEPARTMENT:
DATE:
N/A:
PLEASE NOTE
All stumps and/or brush must be disposed of at an approved site.
COMMENTS:
Or Yq V
Rio TOWN OF YARMOUTH
a<
Fi:,:„s•�y BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT.
Job Location:
Number Street Village
Owner of Property:
Construction Supervisor:
Name License No. Phone No.
Address:
Licensed Designee:
(If other than Supervisor) Name License No.
2.15 Responsibility of each license holder
2.15.1 The license holder shall be fully and completely responsible for all work for which he is supervising.
He shall be responsible for seeing that all work is done pursuant to the state building code and the drawings
as approved by the building official.
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration,
repair, removal or demolition involving the structural elements of building and structures only pursuant to
the state building code and all other applicable laws of the commonwealth, even though he, the license
holder, is not the permit holder but only a subcontractor or contractor to the permit holder.
2.15.3 The license holder shall immediately notify the building official in writing of the discovery of any
violations which are covered by the building permit.
2.15.4 Any licensee who shall willfully violate subsections 2.15.1, 2.15.2 or 2.15.3 or any other section of these
rules and regulations and any procedures, as amended, shall be subject to revocation or suspension of
license by the board.
2.16 All building permit applications shall contain the name, signature and license number of the
construction supervisor who is to supervise those persons engaged in construction, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 of the code and these rules and
regulations. In the event that such licensee is no longer supervising said persons, the work shall immediately
cease until a successor license holder is substituted on the records of the building department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities under the rules and regulations for licensing construction
supervisors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE.
I have a current liability insurance policy or its substantial equivalent which meets the -requirements of MGL Ch.152
Yes __ No Ll
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond
OWNER'S INSURANCE WAIV R: I am aware that the licensee does not have the insurance coverage required by
Chapter 152 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner I] Agent
Signature: Building Official Approval:
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the 'reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but no more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work: �>E LtOz 1 T(an) Est. Cost
Address of Work / 6 8 EQ- 4-Y tJ/o4��`'r � -
Owner Name: (Z.> o /� lbe z o v
Date of Permit Application: T — / — d I
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
_ Building not owner occupied
_ Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property,
Date Owner Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
OlOceol/evest/patlon
600 Washington Street
Boston. Mass. 01111
Workers' Compensation Insurance Affidavit
Aonlicant information• Pfeaselyll `Ted'tap
>i M C
name: L
location 103
am a homeowner performing all work myself.
I am a sole proprietor _r.d hase no one working in any capacity
❑ I am an employer pros iding workers compensation for my employees working on this job.
C3 I am a sole proprietor general contractor or homeowner (circle one) and have hired the contractors listed below who Ita%e
the following worker compensation polices:
City' phone 0-
Failure to secure coverage as required under Section 25A of MGL 152 as lead to the imposition of criminal penalties of a fine op to SIb00.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. 1 understand that a
copy of this statement maybe forwarded to the Ogee of Investigations of the DIA for coverage verifieadoo.
I `do hereby cerii • under th dint anddpe firs of perjury that the information provided above is true and comecL
Signature- .t Date r l —
Print name �O'`'� / 1• c �i`1 Phoneg 38 r— / 407
use oniv do not write in this area to be completed by city or town official
city or town: YARMOOTB.
O check if immediate response is required
contact person:
permitlicenseN m0uildiog Department
[31 Icensing Board
261 OSelectmen's Office
(508) 398-2231 eat. O1lealth Department
phone N: _ _ mother
onnN 1.9% PIA.
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. -\s quoted from the 'law". an employee is defined as every person in the service of another under am
contract of hire. express or implied, oral or written.
An employer is defined as an indiv idual, partnership, association, corporation or other legal entity, or any mo or more of
the foregoing enga ,ed 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 hay ing 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 urounds or buildinct appurtenant thereto shall not because of such employment be deemed to be an employer
\IGL chapter 15, section_5 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supply ing company names. address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The
affidav it 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.
City or Towns
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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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
�tnee of Investigations
600 Washington Street
Boston, Ma. 01111
fax 0: (617) 727-7749
phone 4: (617) 7274900 ext. 406, 409 or 375
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 260
PLEASE PRINT:
DATE: S—/ —O 1
JOB LOCATION:r/, d .
"HOMEOWNER".
NAME
PRESENT MAILING ADDRESS
Y,4A44t uT,
HOMEOWNER LICENSE EXEMPTION
@ 8 J5,7 Y
STREET ADDR
3 85— — j
HOME PHONE
SECTION OF TOWN
Er1TQ9V
O'Z fo
T
CITY OR TOWN STATE ZIP CODE
The current exemption for `Homeowner' was extended to include owner — occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that such
homeowner shall act as supervisor. (State Building Code Section 108.3.5.1)
Definition of Homeowner.
Person(s) who owns a parcel of land on which he / she resides or intends to reside, on which there is or is intended
to be, a one or two family attached or detached structure assessory to such use and / or farm structures. A person
who constructs more than one home in a two-year period shall not be considered a homeowner; such "homeowner"
shall submit to the building official, on a form acceptable to the building official, that he / she shall be responsible for
all such work performed under the building permit. (Section 108.3.5.1)
The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
C
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch 142.
Yes No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance pohcy>k�_ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by Cha ter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner —or Owner's Agent Owner ❑ Agent ❑
nnomwwnnk mp
TOWN OF YARMOUTH
1146ROUTE28 SOUTHYARMOUTH MASSACHUSETTS026644451
Telephone (508) 398-2231, ExL 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at l0 8 P�,4Ay' CA72s4 /C_t .
Work Address
is to be disposed of at the following location:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
S"-/-6/
Date
Permit No.
PLOT PLAN
AbuttorIs
Name
Lot #
If this is a
corner lot,
write in name
of street.
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines --------------------
Sewerage disposal (cesspool)
Well Lo
SIDE YARD
(lot................ft. rear)
I
REAR YARD
.............ft.
I
SIDE YARD
FT O
G 2F—E4.)
I
SET BACK
(lot..................ft. frontage)
(NAME OF STREET)
Information
Supplied by
AbuttorIs
Name
Lot #
If this is
corner la
write in
name of
is
other
bstreet.
MARK NORTH POINT
i
Application to
Old King's Highway Regional Historic District 01imittet —
in the Town of Yarmouth for a �✓`'
T (h.a10:36
CERTIFICATE FOR DEMOLITION OR REMOVAL � � D
Application is hereby made m triplicate, for the issuance of a Permit for DemoIrtim Orrtemt 1 of a building
or a structure or part thereof; wider Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for
Proposed work as described below and on plans, drawings or photographs accompanying this application for.
TYPE OR PRINT LEGIBLY C '-7 DATES / II , 9, aoo/
ADDRESS OF PROPOSED WORK �ji 0 Q r -�Qrm i�i • ASS RSo$SE MAP No. JT/
OWNER iMl Dt yd -IN1l ASSESSORS LOT NO
HOME ADDRESS iC7 e Ad Oo • Wr/I7/ cYh TELEPHONE NO.
AGENT OR
NO j -9 COI
✓ U U Y/l WPO;ED
'OUiN (Qi.;,'JITTE�JV)jO1
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERS C.V o =K�/ 1�J
DETAILED DESCRIPTION OF PROPOSED WORK. If building is to be removed, give new location. Snap shots
shoring all views of building must accompam application. Use additional sheet, if necessary.
hamf n cie"� Ze 6,� N-h d e ark 4-1-7 e �¢ o% 7�e "i
D`-D 'I"z 4�o�z<c t(- 404,,fr-- PPr s¢`77`.oe�tAl Se.t�
Note: If approval is granted for relocation. a separate Certificate of Appropriateness is required for new location if rithin
the Old King s High%%av Regional I listoric District.
Signed Ox--,/
Owne
Space below line for Committee use onh•. rLwtraa r- gent
Received by OKIiC
Date f This Certis hereb%- L.I Datel 1-)
Check p
By i.
APPROVED O YMPOR AN' : If Certificate is approved, approval is subject to the 10 day appeal period
provided in the Act.
DISAPPROVED 0 Please return to: Yarmouth OKHC District Committee
Yarmouth Torn Hall, 1146 Route 28, S. Yarmouth, MA 02664