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issue date
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EXPRESS BUILDING PERMIT APPLICA ,
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
/,It�l � 6cF'ARTM �
South Yarmouth, MA 02664 g�BE. _'
(508) 398-2231 Ext. 1261
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CONSTRUCTION ADDRESS: —7 ". 3 "/ v ' /� /444,4,4,c,
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: s 7 .6y/t„ % eA,•- 5 7 ?.SeCgiCn
NAME //�� ! PRESENT ADDRESS TEL. #
CONTRACTOR: �"L—(//G 5'. Pe y�.�4/ 26 C1.44 N jt(7' C-,PO- `J ag
NAME J MAILING ADDRESS Cj/; TEL.#
❑Residential €ommercial Est. Cost of Construction$ .6?,� '4?'"'C -7
Home Improvement Contractor Lic.# /5 3 ' �3 Construction Supervisor Lic.# / .* 6 / O -"
Workman's Compensation Insurance: (check one)
I am the homeowner ❑ I am the sole proprietor E: I have Worker's Compensation Insurance
Insurance Company Name: / 1- ��.._I' Worker's Comp.Policy# - iwe'c >22c.4
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares /6 Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at:
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date:
Owners Signature(or attachment) ® 1/ Date:
Approved By: Date: N. )0 s� 6
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes E No Flood Plain Zone: Ei Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes 0 No D Yes No
The Commonwealth of Massachusetts
f _� �� 1, Department of Industrial Accidents
1 Congress Street, Suite 100
=R- Boston, MA 02114-2017
..5• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
/�
Name (Business/Organization/Individual): C
Address: C7 ,
City/State/Zip: __ Phone : Sad �-3 7
Are you an employer?Check the appropriate box:
Type of project (required):
I g I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp. insurance required.] —
9. Li_
Demolition
3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t -
10 Building addition
4.I1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will —
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs
These sub-contractors have employees and have workers'comp. insurance.i
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
152,§1(4),and we have no employees. [No workers'comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp. policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. rr: l,'.C. 5 j /8 S9 a9cg e Expiration Date: 4/1/3a4c,2 0
Job Site Address: S .( 5Lp r a- City/State/Zip: GL�. .�
Attach a copy of the workers' compensation policy declaration page(showing the policy number an expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the ains and penalties of perjury that the information provided/6.
bove is true and correct.
Signature: Date: 2 / C
Phone#: 5�r% '-3"?. OrS f �?
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License 4
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone m:
F2 E AL TY
299 Main Street, West Yarmouth, MA 02673
508-775-6880 Fax: 508-775-6939
E-Mail: horansh@comcast.net
February 4, 2020
To: Town of Yarmouth Building Dept
From: Shawn Horan
•
Re: Foxwood Condominiums Building G
To Whom it may concern,
Please note that CF Remodeling Inc has been retained to install siding to building G at
Foxwood Condominiums, 248 Camp St, West Yarmouth MA..
Sincerely yours,
Shawn Horan
Cape Realty Inc
SALES RENTALS REAL ESTATE MANGEMENT BUYER AGENCY
www.caperealtycapecod.com
Commonwealth of Massachusetts /
1"4-1Division of Professional Licensure
JJ Board of Building Regulations and Standards
Const\ru>rt$/f%bpe,rvisor
C$ 1. g4107 > b 4,1 Spires:08/25/2021
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