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22-EB026 33 Squirrel Run Rd Approvedk� v 0 -( -,T-lv T`- 1!5 `_� I\ /t kArl ����' CA Office Use Only Q� t + Permitfl f of Amount HwYrn n cst/�� '•'01" Permit expires ISO days from issue date —^---:H1 PRESS BUILDING PERMIT APPLICATION RECEE TOTN OF YARMOUTH Yarmouth Building Department ����� I MAR Z 22 1146 Route 28 Yr,hcfUSouth Yarmouth, MA 02664 MAR 1 0 2022 QLpKING'SHWAY (508} 398-2231 Ext. 1261 YARMOUTH CONSTRUCTION ADDRESS; 33 Squirrel Run Road L2LDKING'S�trAY ASSESSOR'S INFORMATION Map: 123 1Parcel: 77 OWNER: Lynne Clancy 33 Squirrel Run Road Yarmouthport, MA NAME PRESENT ADDRESS TEL. CONTRACTOR: Mark Clancy P.O. Box 249, South Denni: 5082404404 NAME MAILING ADDRESS TEL.:f ©Residential OCommercial Est. Cost of Construction $ 151 000 Home Improvement Contractor Lie. #179722 Construction Supervisor Lie, 41CS-057138 Workman's Compensation Insurance: (check one) 1] 1 am the homeowner 13 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Associated Employers Ins. Worker's Comp. Policy# WCC500501382022A WORK TO BE PERFORMED toveSTent _E1 Duration (Fire Retardant Certificate attached?) Wood Stove- Siding: iding: # of Squares Replacement windows: # Replacement doors: # Rooting: # of Squares (Fv�) Remove existing* (max. 2 layers) lusulation-El Old kings Highway/Historic Dist. (Ep Replacing like for like (ON Pool fencing pp VV;2 r *The debris will be disposed ofat S&J EXco, 200 Great Western R ad, South Dennis MA 02660 1 declare under penalties of pe tisill be just cause far dVJil Applicant's Signature: Owners Signature (or ntt�chh Approved By: I Building Location of facility i tatements herein contained are true artd correct to tate best of my knowledge and belief. I understand that any false answer(s) my license and for prosecution under M.G.L. Ch. 268, Section 1. V_ (or designee) EMAIL ADDRESS: Date: Date: Date: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 fl. of Wetlands: Yes No Yes No ,a)-6\�0a to Sherman, Lisa From: RICHARD GEGENWARTH <r.gegenwarth@comcast.net> Sent: Thursday, March 10, 2022 2:20 PM To: Sherman, Lisa Subject: Re: 22-EB026 33 Squirrel Run Road Attention!: This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Definitely like for like so I approve. Richard On 03/10/2022 2:08 PM Sherman, Lisa <lsherman@yarmouth.ma.us> wrote: Hi Richard, Request to replace roof (Pewterwood); current color is also gray. Please let me know if you need any additional information. Thanks Richard, Lisa Lisa Sherman Office Administrator Old Kings Highway Committee/Yarmouth Historical Commission Town of Yarmouth 508-398-2231, ext. 1292 Ishennan@yarmouth.ma.us APPROVED MAR 10 2022 YARMOUTH OLD KING'S HIGHWAY The Corntnonwealth of Massachusetts RECEIVED Department of lndustrialAceidents MAR 1 0 2022 1 Congress Street, Suite 100 Boston, MA 0.2114-2017 ' 5•''4 www.mass.gov/dia OLD KING'S HIGHWAY lVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electriciansiplumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lcgibl Name (Business/Organization/Individual): Clancy & Castano LLC I Address: P.O. Box 249, 17 American Way 10`2'022 City/State/Zip: South Dennis, MA 02660 Phone #: 5082404404 Are you an employer? Check the appropriate box: I. z I am a employer with 3 employees (foil and/or part-time).* ? F1I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I an a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.M [ 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 proprietors with no employees. S. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.t 60we are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1 (4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. New construction 8. Remodeling 9. ❑ Demolition I0 Q Building addition 11. E] Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. Roof repairs 14. Q Other nrry appi1canc LMAL cnecscs oox rr r must also tiu out the section below showing their workers' compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance company Name: Associated Employers Insurance Co. Policy 4 or Self -ins. Lic. 4: WCC500501382022A Expiration Date: 1/1/2023 .lob Site Address: 33 Squirrel Run Road City/State/Zip: Yarmouthport Attach a copy of the workers' compensation policy declaration page (showing the policy number and 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 certii yzVe-�th5,*irs—and penalties of perjury that the information provided above is true and correct. 3/10/2022 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: PermitlLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ;0 MAR 10 2022 Office of Consumer Affairs and Business Regulation r Hrttvivu + 1000 Washington Street - Suite 710 KINGS H1GHVM_'J Boston, Massachusetts 02118 Home Improvement Contractor Registration CLANCY & CASTANO LLC P. O. BOX 249 -� .- SOUTH DENNIS, MA 02666 I MAR 1 0 2022 YARU'aU << 20M-05/17 .�i�.�r�aryrcvrrrie�cl%i c�,T��ssr�cl���/G3 Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: LLC Registration Expiration 09/01/2022 CLANCY & CA.STAN9 [ L C MICHAEL CASTAN60,43 17 AMERICAN WAY ��` UNIT 3 -. SOUTH DENNIS, MA 02660 Undersecretary Type: LLC Registration: 179722 Expiration: 09/01/2022 Update Address and Return Card Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston, MA 02118 Not valid Mt-ioyiignatla e