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BLD-17-001357 $ .•YRR /�� 7� Office Use/O,�+nly1 , I 1> p 1& r// / /"G�;. tiz . y � 6/3 /7 0 /5f Sl� il,) 1ir�cn csc,� �Amount 1Permit expires 180 days from i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 S f-e v0 .r) 411611 South Yarmouth, MA 02664 AUG 10 2022 (T' I./Le f (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: �,4t&Jk,4A/N,g(lK/,�t- OR/VC BUILDING DEPARTMENT f0, yAR/1l0 u4-# • ASSESSOR'S INFORMATION: Map: Parcel: OWNER: A ,,i3O. jcL f'P tiT,vNAWKlt+ NAME S��= 'f3�—�a�lj� PRESENT ADDRESS TEL. # CONTRACTOR: NA�//. /. ✓ 0 MAILING ADDRESS�he- .fr,�1e'( � A c .�l©r-20�`1—? /.'L 014 ys" TEL.# Residential ❑Commercial Est. Cost of Construction$ h/Oa.no Home Improvement Contractor Lic.#_� �� rf y493r Construction Supervisor Lic.# /19#1/5 9 Workman's Compensation Insurance: ,(check one) 0 I am the homeowner I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares O 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: 1424C 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 I. Applicant's Signature: Date: Owners Signature(or attachment) I os/i t7 I2U Z� Date: Approved By: ✓ 1 �, 1 O Building Official(or esignee EMAIL ADDRESS: Date: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 / imil 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): ffE rA) Au y2.Z to Address: /O A't fit c G 12'C City/State/Zip: MRRu;icw; ,4 c'1 v&' Phone #: 57r lYP— 9%2,42 Are you an employer?Check the appropriate box: Type of project(required): i.cilarn a employer with employees(full and/or part-time).* — 2.1E1 am a sole proprietor or partnership and have no employees working for me in 8 7. R Newm construction any capacity. [No workers'comp. insurance required.] 8 E Remodeling 3.111I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. [1] Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my I will 10 [ Building addition ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees. 11.[ Electrical repairs or additions 5.[I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.1 13•[Roof repairs 6.[We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[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. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 pains and penalties of perjury that the information provided above is true'and correct. Signature: /10" -G/ 914 ju .l -IG Je'�? Date: Phone#: 5 e jJ- Official use only. Do not write in this area, to be completed by city or town official. City or Town: 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#: 7�ffggatetmsatresrl/ ai &gisitatwss egeGNion HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration • 147634 07/24/2023 STEPHEN P MAZZLiR D/B/A STEPHEN P.MAZZUR HOME IMPROVEMENTS STEPHEN P.MAUR 10 MARK LANE a! HARWICH,MA 02645; Undersecretary • Commonwealth of Massachusetts • Divion of Professioniil Licensure • Board WBuilding R ulttttons and.Standards Cgnir 14r • 1?5-104459 * .. ot=es:,09;02i2023 t STEPHEN ►IJX ;* .n 10 MARK,LA Q HARWICH M ol. 3CIT` Commissioner (: .rtelia . 8'ern• • • •