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Home My WebLink AboutBLD-19-000926 r� - c Use Onl ill {:e - A2,ro �-/ -app15W,i PermoW `'telOH: nAmuunl (OJ-�3 t n sl/4 %rd' Permit expires 180 days from 'r tissue date !' EXPRESS BUILDING PERMIT APPLIC ' IIONC ti I V E Ed TOWN OF YARMOUTH Yarmouth Building Department AUG 1 q 20113 1146 Route 28 South Yarmouth,MA 02664 (j?; tPq F2TMt r/ i (508)398-2231 Ext. 1261 - -- ' CONSTRUCTION ADDRESS: 923 Rt 6A Yarmiuth Port Sunflower Market Place Building 4 ti�_ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Chapter Two LLC PO Box 206 Yarmouth Port 508 423-9311 NAME PRESENT ADDRESS TEL il CONTRACTOR: James N Basler Box 366 Yarmouth Port 508 423-9311 NAME / MAILING ADDRESS TEL R 0 Residential /Commercial Est,Cost of Construction$ $12,000 Home Improvement Contractor Lie.# 181241 Construction Supervisor Lie.# 012929 Workman's Compensation Insurance: (check one) 3 I am the homeowner K 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 2 Replacement windows:# Replacement doors: # Roofing: #of Squares 35 ( 1)Remove existing*(max.2 layers) Insulation ✓ Old Kings highway/Historic Dist. (✓)Replacing like for like Pool fencing "The debris will be disposed of at: S &J Location of Facility I declare under penalties of�gerjury 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 revocatio of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature; J/ l ,A n Date: 8/16/2018 Owners Signature(or attachment) n / P\\_ / Date; 8p/.16/[2018p Appmvcd By: ,./�„V- v Date: 0 -I tl -i d Building Official(or designeef EMAIL ADDRESS: jbasler@ Comcast.net Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes D No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • ---• . The Commonwealth of Massachusetts I —=74=r=li=tit Department of Industrial Accidents a -4101_ 1 1 Congress Street,Suite 100 ' _4 .i . Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leiibly Name(Business/Organization/Individual): James N Basler Address: Box 366 City/State/Zip: Yarmouth Port MA 02675 Phone#: 508 423-9311 Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with 0 employees(full and/or part-time)." 7. 0 New construction 2.1711 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13.[J'Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.gOther Siding 152,11(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. tConuactors 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 ant 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.Lie.#: Expiration Date: • Job She Address: 923 Rt 6A Yarmouth Port MA 02675 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 cnder the ains and penalties of perjury that the information provided above is true and correct Signature: Ak. Date: April 9, 2018 Phone#: 508 423-9311 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.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: