HomeMy WebLinkAboutBuilding Permitstom -
BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: —J / w/�%7'�� .Jf, YF2�lo c1TN �o� MA-,
omce tae ab
Permnt a -
Fa S
Permit espims 6 months Bum
issue dab.
ASSESSOR'S INFORMATION:
L Parcel: 9 Z
.AE
ADDRESS
CONTRACTOR: IlUffl ri V w�
NAME
❑Commercial
—342 — yz1i
t I:LA /
CIO
Est Cost of Construction f 146,001
Home Improvement Contractor Lic. 0 Construction Supervisor Lia 0
WorkmAqKs Compensation Ince rmm (check one)
If I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compcnntion Insurance
Insurance Company Name Worker's Comp. PolicyA
WORK TO BE PERFORMED
0 Ted (Firs Rdardust Certi6cats aaached)
Duration Wood Stave Shed
L i 'dons: k of Sgwres—'�--r 0 Replacement windows: 0
Oftlaeemeat doers: s
0 Re -mor p of Squares
() Stripping old shingles* () going aver lsyes of existing roof /Old Kings Mghway/Historio District
. Roormg/Siding (L Ls for Us)
*The debris will be disposed of at:
I declare under penalties of pajury4d the slatemmts
will be just cause for denial of rIA00n of V lids
Applicant's Signab".
owners Sigrnatme
ssained an true and correct to the bel of my knowledge and belicE I understand that any Was answer(*)
prosewaioa under 1d.O.L Ch. 269, Section 1.
Approved By Data:
BuildingoE&isl (or designee)
Zoning District: —g=—
Historical District V Ya 0 No
Water Resource Protec ' District
Yes No
Flood Plain Zone ❑ Yes Q/No
Within 100 es of W No
"
❑ Yes �� No
3.01
j
The Commonwealth efManaehusetts
Department of Industrief Accidents
' Ofj?ee of Invest(gadons
600 Washingtoe Stred
Boston, MA 01111
www.mass.govIdla
Workers' Compensation Insurance AWdavit: Bailden/Contractors0ectrklans/Plumbers
W-7
tb G .
Address: -42 W /a)71 d= T' ,
au 25 Phone 0:
Are yon as emp*srt Cheek eke appropriate boss
1. ❑ I am a employer with
4.01 am a general contractor and i
employees (W aad(or part -firm).•
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attacked skeet.
ship and have no employees
These subcontractors have
working for me in any capacity.
enployces and have workers'
[No workers' comp. insurance
coop. knatnaoce.t
]
S. [I Weare a corporation and its
3. 1 am a homeowner doing all work
o®cere have exercised their
mysclL [No workers' comp.
right of axemptlm per MOL
insurance required] t
c. 132, 11(4), and we have no
employed. [No workers'
com insurance reauhv&l
Type of project (required.
6. ❑ New consttuctioa
7. ❑ Remodeling
g. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.13 Ph®bing repairs or additions
12.0 Roof repairs
13.[] Other
•My eppllaot ere checks boa Q mart abo n/ WA dw sand= below sba"W stir mko ,
t Homeowners wfw m rnk Us aid"t t O0� try id6mrtfoL
tCont mon *At cbeck floes boa mar nddr ere aMdoW awd tit work d era kf @Nide coatrsnn met s wbo a new a�lldrrit irdiatlna arc`
abowina Ws reser. of er and stay wbaWar or sot Woes eltdtlss Irw
wVWY es. If dw VA-= scbn haw aMWYm. Wry met prorlds Wei vmkws' cora, poky snubs►
,raw aw ewpbyw that lr p vWdlws tvorkm' compexsalbw buxreaeo for dry cv p/pym tido..ls fA� policy owl fit stat
Informad�
Insurance Company Name:
Policy N or Self irs. Lk. N: Expiration Date:
Job Site Address: City/Ststeff5p:
Attach a copy of the workers' compensation policy declaration pap (showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of b10L c. 152 can lead to the WIPOEitim of taindnal penalties of a
fine up to S 1,500.00 and/or one ;year imprisommnt, as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to 5230.00 a day against eke violator. Be advised that a copy of this statement may be forwarded to the O[&C of
_e.L_ .ter. I- ._ _ ._
I do hereby eerdo
and pe'dwa Of pequry teat MI Infernedon provided about 4 tow awd eorrecL
11
Information and Instructions _..
Massachusetts General Laws chapter 152 requires all employdrs to provide workers' compensation for their C V'#) ev
Pursuant to this statute, an emptgw is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An empfeyar is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
ed in a joint enterprise, and inchuft the legal representatives of a deceased employer, a the
re the foregoing engaged g 1 association a other legal entity, employing employees. However the
Owner o a dwelling
o[ as is having parinenhiP+ and who resides therein. or the occuPed of the
owner of a dwelling house having not more shoo three apartments as work on such dwelling house
dwelling house of another who employs persons to do msintenaoce, constriction airrep
or on the grounds air building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter IA f 23C(6) also states that orrery state or local licensing agency 56211 withheld the Issuance or
renewal of a "COMM or permit to operate a business or to constrict buildings le the commonwealth for say
applicant who has net produced acceptable evidence of compU2neo with the Insurance cover go required.
Additionally, MGL chapter 152, i25C((7) states "Neither the can monwealor any Of
of ips lits c l subdivisithe ono shall
enter into any contract for the performance of public work until acceptable»
nce
requirements of this chapter have been presented to the contracting authority.
AppUc2nb
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub4ontractor(s) nauue(s). address(cs) and phone number(s) along with their certificate(s) of .
insurance. Limited Liability CorMania (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation lomrance. If an LLC or LLP does have
s affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. tun .
employees, a L required. Be advised that this Abe be sto sigh and dab the affidavit. The affidavit should
onH
be returned to the city or town that the application the �tth r law s ifs being requclte4, net the Dclm"30d You am reunited obtain a worker' of
Industrial Aapolicy Should you have any questions � � below. Self-insured companies should enter their
compensadnn'poliry,Piease call the Department at
self-insunmee license number on the tt lid.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be we to fill in the pemrit/license number which will be used as a reference number. In addition, an applicant
that mast submit multiple perp itilicense applications in any given year, need only submit one affidavit indicating current
Policy infonnsdon (if necessary) and under "Job Site Address" the applicant should wry town ms be in
vided to (the Of.
town)." A copy of the affidavit that has been officially stamped or marked by city y Pro
applicant as proof that a valid affidavit is an file for future permits or licenses. A new affidavit mast be fulled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license of permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not besitate to give m a call.
rhe Department's address. telephone and fax number.
The Commonwealth of Massachusetts
Department of Indttstrial Accidents
oMet of Investlptions
600 Washington Street
Boston, MA 02111
Tel. 0 617-7274900 est 106 or 1-877-NIASSAFE
Fax 0 617-727-7749
Revised 11.22-06 www.mass.gov/din
r �l.
�JT'LAR�'cIU11N M 1AMMULA111
BUILDING DEPARTMEN r
1116 Route 28. South Yarmouth. 11r1 o1 JUL 2 U M9
o.
408-398-22131 ext. 161 Fax -'08-398-083
•• •-�t3�V•kr3fN" •
l
ZONING DETERMINATION FOR BUSINESS CERTIFICATE:' PPLICATION
The purpose or" form is to determine whether your business complies with the Town of Yarmouth Zoning
Bylaw. The applicant shall complete the top section or this form and file it with the Building Department.
Once the Building Department has made a determination, it -will be forwarded to the Town Clerk.
The Building Department will render a determination bssed Un the following factors: (a) The husincx"se,
acdriQr, (b) Yhe,Caning rlfsrricf in which the business is la be hxaterL Allin rd uses are baser/nn Ziming 4-hrw
Tahk 2025 and (c) PM•ious nr nes zoning rr lieflnxw theZuning &card uj.4ppeuh
Date / —Is—o/
Business Address "S"/
-L
Mame of
Description of Business Activity qt.,,. -7 owow;np
6
The applicant acknowledges that a determination will be made by the Building Department baud on the
information provided on this date and any changes is the business use and/or activity will require additional
approval. Failure to do so may result in the revocation of the Business Certificate and/or appropriate Zoning
Enforcement. should it be determined that the changes are non-compliant.
Applicant's Signature��-� Date 7AS/q
BUILDING DEPARTMENT Dx£ rf 1 lxxknom
(office use only)
Approved
Comments
Disapproved
Reason for Disapproval
Buildiu9 Otticial's Signature
Po Ik. to :41,17 -
hVC4�
TO 39Vd NOSNVMS TTZbl9fi809 VT:00 60OZIOZ/L0
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BUILDING
TOWN OF YARMOUTH PERMIT
jiW3 FIELOPY
D .
%3-0P-070 7Ir1a/
, DATE July 18• 2001 PERMIT NO. 5-02-070
S
id 6 Sh
veree Swanson Winter Street Y.P. ` )_
APPLICANT DaADDRESS51 WitStt Y 02675
P
• (NO.) (STREET) (CONTR'S LICENSE)
PERMIT TO reDairt3• (_( STORYNUMBER
—DWELLING OF
UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE) '
51 Winter Street Y.P. 02675 ZONING R40
AT )LOCATION) DISTRICT
(NO.) (STREET)
BETWEEN AND
(CROSS STREET) (CROSS STREET)
SUBDIVISION- 132/72
LOT_
BUILDING IS TO BE
FT. WIDE BY
FT. LONG BY
LOT
BLOCK SIZE
FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE SS USE GROUP R4 BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: residing 2O 3 iunreS
AREA OR PERMIT
VOLUME ESTIMATED COST EE � �5.�_Q
(CUBIC/SQUARE FEET) ^ /.
.�� 4eH�F��.lQ47S�.l�iiRTe7�BUILDING Yo/ � `I
ADDRESS 51 Vlint-nr s 1 �� LL/Q
INSPECTION RECORD
41 DATE I NOTE PROGRESS - CORRECTIONS AND REMARKS I INSPECTOR
;_�1-63
.y�
EXPRESS BUILDING PERMIT APPLICATION
Q 0 i TOWN OF YARMOUTH
JYarmouth Building Department
UL 1 2001 f 1146 Route 28
93 South Yarmouth, MA 02664
3 S (508) 398-2231 Ext. 261
CONSTRUCTION ADDRESS:
ASSESSOR'S INFORMATION:
IN
Permit Y��,,-�6��7V
Fee S ILEV
Permit expiras 6 months fro"
issuedate. -
I Map: 13 z I Panel: 72
OWNER: >401> t 5 genu r Jf*!f)1 ot)Soa CS,1,W& -:52>8 — 36 z
NAME PRESENTADDRESS TEL. K
CONTRACTOR:_ O(..) 6. "4 65"f->
f NAME MAILING ADDRESS TELJI
►J �idcntial ❑ Commercial ESL Cost of Construction S off. 0V
Home Improvement Contractor Lia M Construction Supervisor Lia #
Workman's Compensation Insurance: (check one)
I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compauation Insurance
Insurance\Company Name: s M i e A— :I` /ys . Worker's Comp. Poli
H°�"E- �U£RS �"s:(v�nvr� no n�nc�nwRor
D'Tent (Fre Retardant Certificate attaached)
Duration
idiag: / ofSquares
❑ Replacement windows: 0 0 Replacement doors: M
D Re -roof # of Squares
() Stripping old shingles* () going ova layers of existing roof
'The debris will be disposed of at: )IhdeI,7-W 7_60A) *b L)04,6
Location of Facility
1 declare under pataltia of perjury t the statements herein contained are true and correct to the best of my knowledge and belief I understand that any false snswcr(s)
will bo just cause for denial or rev n of license or prosecution under M.G.L. Ch. 269, Section 1. o
Applicant's Sigm— m vD'` Date: %�sp/t7/
0
OwnenSiguature(orattachm ) Date �',�X��4
Approved BY Date: 7
Buildi Of6ciaf (or designee
Zoning Distric
Historical District: iv Yes ❑ No
Water Resource Protection District:
❑ Yes R�No,
Flood Plain Zone: ❑ Yes W
Within 100 (3. of Welland
❑ Yes 1-4- o
3101
SPECIFICATION SHEET (YARMOUTH OKHC) - SUBMIT 3 COPIES Ow
•, -'�+ Please fill out the form in its entirety providing color chips where
` Hetes 7l� INDICATE LtNDSCAPING,EYTERIORMGHTINGAjjLFq G' ; I ONS /PLANS
FOUSE£
RNEIYHOT0V4\1 /I,L`PK I \
NAME OF OWNER(S)-i!- &,b � � ►9 N ��u
M 11di7-3 iNI U 5p
X.
FOUNDATION ov MAEXPOSED): CONCRE THER DRIVEWAY: iq,5PA l -T
WALKWAY. STEPS (INDICA RI CEMENT �GJ9
SIDING TYPE: INM'I r i; (ffD)92 000b .5/111v%4S COLOR: AT-0j2I4L
CHIMNEY (INDICATE BRICK/STUCCO/WOODFACED) COLOR:
ROOF MATERIAL: PITCH (7/12 MIN.) COLOR:
MAX. EXP.
WINDOWS (GRILLES REQUIRED) -INDICATE SIZES IF NOT LISTED ON ELEVATIONS:
£xi sr, iv9 :
DOORS (INDICATE SIZES AND STYLE IF NOT LISTED ON ELEVATIONS): COLOR: Gfq jg,,- Ta: �2�E.✓
TRIM: (ALL WINDOWS &•H�TRUOIED WITH m / 1X5)
MATERIAL OF TRIM: 00 L, ALUMINUM)
SHUTTERS (WOOD INY (PANELED/LOUVERED)
GUTTERS (WOOD UMINUM • W jf/TE
COLOR: tjg1;�_
COLOR:u1�
(R:
gQfvu
GARAGE DOORS: SIZE & STYLE: _ _ , __ _ -.COLOR:
STORM WINDOWS & i@:- i COLOR:
(INDICATE SIZES IF NOT LISTED ON ELVATIONS) APPROVED
YARMOUTH COMMITTEE
SKYLIGHTS: TYPESIZE: OKHRD COLOR:
DECK: SIZE & MATERIAL:
FENCING (MAX. HEIGHT 6'): STYLE:
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
,COLOR:
COLOR:
RETAINING WALL: (P.T. OR FEELDSTONE-CONCRETE INAPPROPRIATE)
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
SIGNS: (indicate size, style, colors)
SIGN POST: (indicate size, style, color)
ADDITIONAL INFORMATION:
REV. 6/99
COLOR:
COLOR:
6e6T/N1b COCOA
UJ fi`/ r 1E. Cff Z"
-la _g4nW
6AJ,4/ iL
SANOWCH OEM"
'� 'f "" Old King's Highway Regional Historic District Committee
' in the Town of Yarmouth for a Y`t' R IV I O U T H
TOWN C� EPK
CERTIFICATE OF APPROPRIATENESS a
2001 11AY 31 M fix 30
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 proposgtq&� wL'rr& below and on
Plans, drawings or photographs accompanying this application for.
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construeyeti: p New Building 0 Addition p Alteration
Indicate type of building C3' How O Garage 0 Commercial p Other
2. Exterior Painting: W�
3. Signs or Billboards NewSign Existing Sign p Repainting existing sign APPROVED
YAR AOURI COMMITTEE
4. Stricture: p Fence 0 Wall O Flagpole p Other 0KHRO
"TE OR PRINT LEGIBLY p DATE 6/h /L
ADDRESS OF PROPO El) WORK �� ���/� 6t: ASSESSORS MAP NO.
OWNER�A di D 5MV, c<cj
HOME ADDRESS :51 / A)Tg-e- �5',
AGENT OR CONTRACTOR ��–
USE ATTACHED SHEET IN PACKET FOR ABUTTING OWNERS
LOT NO.
' T0.
F�pIVIffa�
i OLD KING'S Ni:'Od lf1Y
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done including materials to
be used. In case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet. if
neassan�•1.
i flMDJ6, Exrsr1�✓9 �ltfrri=c�AH�2s��nlg �arNg ��P >_ 0)i-' CC)
//ir�
slkl,19c£S (,94DA£: AF-kr2A), ROV1101- 4CX JSrinJ9 T -RIM 61WF, Isco X-, 7*AJ7-_
,5X/ST&VQ �xi Ria2 r,J /Ti;�oo�P_S Ta /fi re Coco2 01=- EXrE/Z/21o2 1;t1IIVJ��J .
.6PTT925.
Signed ✓ Sp3, — �eJN�2
Owner ontractor-Agent
Snace below line for Committee use only.
/ R=ived by OKI IC
Date r /�" 1)/This Certificate is herCbv .., r -' w. Z " C� Date
Check 1{ t' `' •'{ L ;.-)L. z\
By-
APPROVED p IMPORTANT:L)ertificatc is approval, approval is subject to the 10 day appeal period
provided in the Au.
DISAPPROVED p Please return to: Yarmouth OKHC District Committee
Yarmouth Town Hall, 1146 Route 28, S. Yarmouth, MA 02664
SPECIFICATION SHEET (YARMOUTH OKHC) - SUBMIT 3 COPIES '609 ,
Please fill out the form in its entirety kp fd,' � � or chips where
necessarNy. INDICATELANDSCAPING,EXTM0RMGHTIIVG&IFCEG L ER SITEPLAIyS
FORNEl OUSE. TOWI\! ! ,Li_
NAME OF OWNER(S).�)y
FOUNDATION (I8" MAX. EXPOSED): CONCRETE/Op WAY:
Cclvt
WALKWAY. STEPS (INDICATE BRICK/CEMENT/OTHER):
SIDING TYPE: 0 91 r£ C011 a Wood 5111 vJ94-S COLOR: 1J4T7144V-
CHIMNEY (INDICATE BRICK/STUCCO/WOODFACED)
ROOF MATERIAL:
PITCH (7/12 MIN.)
MAX. EXP.
COLOR:
COLOR:
WINDOWS (GRILLES REQUMED)-INDICATE SIZES IF NOT LISTED ON ELEVATIONS:
DOORS (IIVDICATE SIZES AND STYLE IF NOT LISTED ON ELEVATIONS): COL
ObfAJUcU9 77>!54f£''
TRIM: (ALL WINDOWS & DOORS TRIMMED WITH 1X4 / 1X5)
MATERIAL OF TRIM: (WO , VINYL, ALUMINUM)
SHUTTERS (WOO (PA NELED/LOUVERED)
GUTTERS (WOO MINUM Wr1lrt,
GARAGE DOORS: SIZE & STYLE:
STORM WINDOWS & DOORS:
(INDICATE SIZES IF NOT LISTED ON ELVATIONS)
I
SKYLIGHTS: TYPESIZE:
DECK: SIZE & MATERIAL:
COLOR: !tel ffl'ri
. CA!;F/ -tj : t�1/fir�
COLOR. tja.Aa
C s/AA�jG 7a
COLOR: £b4sTr^j W rliYL
C'AwflE C.0644- 7'0 S�
_COLOR
,._..: _ tJ ff/ /
APPROVED COLOR:
YAR1111001 COMMITTEE
OKHRD
COLOR:
FENCING (MAX. HEIGHT 6'): STYLE: COLOR:
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
RETAINING WALL: (P.T. OR FIELDSTONE -CONCRETE INAPPROPRIATE)
(SHOW LAYOUT & RUNNING FOOTAGE ON SITE PLAN)
SIGNS: (indicate size, style, colors)
SIGN POST: (indicate size, style, color)
ADDITIONAL INFORMATION:
REV. 6/99
COLOR:
COLOR:
o< r TOWN OF YARMOUTH Building Department BUILDING
. PERMIT NO (508) 398-2231 ext.261
..........
...
old ISSUE DATE 5/11/00 PROPOSED USE PERMIT
5
"' " " • " " SymnsoJOB WEATHER CARD
------.----
APPLICANT •David. .... Swanson
PERMIT TO Repair
AT (LOCATION) 10051WINTERST ZONING DISTRIC R.40 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1132.72 BUILDING IS TO BE: CONST TYPE 1E USE GROUP R-4
LOT SIZE O
residing 7 squares
REMARKS
AREA (SO FT) EST COST ($ $1,000.00 PERMIT FEE ($)
OWNER SWANSON, DAVID B BUILDING DEPT BY
ADDRESS 10051 WINTER ST
Yarmouth Port MA 02675
CONTRACTOR
LICENSE D
PHONE 1508W24211
INSPECTION RECORD FIELD COPY
Date Note Progress - Corrections and Remarks Inspector
HEDS LESS THAN 150 SQ. FT. SHALL
E PLACED A MINIMUM OF 30 FEET
ROM THE FRONT LOT LINE AND A
IINIMUM OF ra FEET FROM SIDES AND
.EAR LOT LINES.
BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 261
CONSTRUCPION ADDRESS:
ASSESSOR'S WFORMATION:
n
OWNER: 1��1J�W
NAME
CON?RACTOR:
Parcel:
SS ;40/1/nr/rXaft3,(7- TEL N
FegZ�_
['erm k expires 6 to Abu
sad date.
NAME NAILING ADDRESS TEL.g
06
Rtsiderrial ❑ eomrtertaal Est Cost of Cosa„ctiot S
�o�
Home Impovunent Contractor Lie 0 Caution supervisor Lie. 0
WManatr•s Compensation Insurance. (check me)
0 1 am tier+ homeowner 0 1 am the sole proprietor 0 1 have Worker's Compensation huu ance
kmrw= Company Name: Workc's Comp.
WORK TO BE PERFORMED
0 Tau (fire Retardant Ccrtifiategvchaq
r Duration wood stove
t3S zw M of sgam. J� 0 Replacement window
a Repbamcm doom M
❑ R>roof 0 ofSgaares
() Stripping old Ammon'
nW debris will be disposod ofat: _ Y9
04A
() goos over layers of —i."a roof
RECEIVED
MAY 11 2007
KING'S F':YGHWAY
Location of Facility /
I declare under peraltics ofand bdn
11101 the stataaats 6acin eoatainedare bee and cotreu to the bat of rry knowkdge ie[ 1 nderpaad tlrt ray Else answa(s)
will be just cruse far denialpw notion ofd license and for prosaaiiop under KQ.L. Ch. 268, Section I.
Applicant's Signature: . Date:
Owotrs Signature (or attschmau ���
Date:_J�/�,
Approved By Date:Bunldmg Otbcul (err destgnce)
Zoning District:
Historical District: VYes 0 No Flood Plain Zone: 0 Yes No
Water Resource Protelction District: Within 100 R of Viedandw
❑ Yes ❑ Yes No
W01
Tire Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): (J t%t:> /J
Address:�l I S�
City/State/Zin:%/�/YtO tJ7�1 Phone #:
Are you an employer? Check the appropriate box:
Type of project (required):
1. [1 I am a employer with
. am a general contractor and I
4 ❑ I
6. E] New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g, ❑ Demolition
working for me in any capacity.
employees and have workers'
insurance.:
9 ❑ Building addition
[No workers' comp. insurance
comp.
❑ We are a corporation and its
10.❑ Electrical repairs or additions
kcquired.,5.
maomeowner doing all work
officers have exercised their
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.[:] Roof repairs
insurance required.] t
c. 152, 1(4), and have no
13.0 Other ,
employees. [No workers'
comm insurance required.l
Any applicant that checks box #1 nest also till out the section below showing their workers' compensation policy information.
t }lorneownen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation Insurance for my employees. Below is the policy andJob site
information.
Insurance Company
Policy # or Self -ins. Lic.
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a foe
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
I do hereby certify
v_
use
City or Town:
area, to
that the information provided above is true and correct.
Date: J`�/Il o 2
or town gfJlclaL
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 #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employbrs to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for, the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to 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. In addition, an applicant
that must submit multiple permit/liccnse applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 11-22-06 Fax # 617-727-7749
www.mass.gov/dia
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING
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OWNER'S INSURANCE WAIVER: I am aware that Ute Ikens" does not Nve the Iraurance coverage reduced Dy
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nature of 0,wrwa I Agent ;rr
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MASSACHUSETTS UNIFORM'APPLICATION FOR PERMIT TO DO PLUMBING
(Print Type)
10-4—Z-37 Fr Mass. Date Permit 9 n
1 -4 — Z37
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– Building LocationTJ �V n
Owner's Name_.���cJL!%ij7
Type of Occupancy
New ❑ Renovation ❑ Replacements Plans Submitted: Yes ❑ No O
same of Licensed Plumber
FIXTURES
i r'�umAril:t COVERAGE: --
I rave a current liability insurance policy or fts substantia) equivalent which meets the requirements cf MGL Ch 142.
Yes O No O
It you have checked ves, please indicate the type coverage by checking the appropriate box
,a Iztillty insurance pciicy C Other type of indemnity p Bond ❑
I O e/NER'S INSURANCE WAIVER: I am aware that the licensee does_ not have the insurance coverage required by
C;:apter 142 of the ).lass. General taws, and that my signature on this permit application waves this requirement.
Y' Check cne:
cnagztmraGer o�Owner ❑ Agen: ❑ On
Sha: ed i �,rJry that ai of the details and information I have submitted (or entered) in above application are trua and a=Nta to tha best Cl my
Ke•.ge and that all plumbing work —,-,d installations performed under the permit issued f this appfcaGon will ba in ampliance Kith JI
neat provisions o1 tnz Mas-ichu ;atts State Plumbing Code Ch' ter 142 o the Ge ral Laws.
lilVA Aiiiiiii /J A Signaturtt Luanszd Plumber
Typc of License: Mea �i
as Journeyman
%.r^ f�,:D 1CrriCc USc Cr�LY) Licanse Numb—
of Ir TOWN OF YARMOUTH Building Department BUILDING
1 (508) 398-2231 ext.261
'- PERMIT NO _8-10 390 -
y ISSUE DATE :_ 9(29/2009.: PRGPOSED US PERMIT,
..""".""....---- JOB WEATHER CARD
APPLICANT ,David Svr... :
PERMIT TO Repair
AT (LOCATION) 10051W INTER ST ZONING DISTRICT R-40 Bldg. Type: Residential
SUBDIVISION MAP LOT BLOCK 1132.72 BUILDING IS TO BE: CONST TYPE Efl USE GROUP R.4
LOT SIZE
residing 4 -5 squares
REMARKS
AREA (SO FT) EST COST ($)$2.000.00 PERMIT FEE ($) $35.00
OWNER ISWANSON, DAVID B BUILDING DEPT BY
ADDRESS 0051 WINTER ST
Yarmouth Port I MA 102675
CONTRACTOR
LICENSE
PHONE 15083624211
INSPECTION RECORD FIELD COPY
Date Note Progress - Corrections and Remark Insaector
M1
CS*n
F
I12111/2014 SlipGen - Portal Hone
Town of Yarmouth
Template [Building Dept]
Slipsheet Identifier [sg10154]
Document Category Building Permits
Map -Block Number 132.72
Street Number
0051
Street Name
WINTER ST
Department
Building
Parcel ID
15396
Backfile Batch Scan
No
Document?
Additional Naming Info
Index Operator
Operator, Yarmscan
Date - Time
2014-12-11 - 08:53
httplllaserfiche12(SlipGerJ 111