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Home My WebLink AboutBLD-19-1413 IAkOE Y444 Office Use Only -f;.*". rO- a Permit# yy . i ' _ Su!j H�$ Amant a Permit expires 180 days from ` =41: . issue date ' 1316-'-'114--bpI I . EXPRESS BUILDING PERMIT APPLICATI S : E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department SEP 10 2018 1146 Route 28 South Yarmouth, MA 02664 BU . o !r•- •• •T, (508) 398-2231 Ext. 1261 BY —' • CONSTRUCTION ADDRESS: -• & ( 1ac�C✓ SLa✓e- \�-A ASSESSOR'S INFORMATION: \'� Map: Parcel: ' OWNER: TC t, `jfla/'% Coce 0 Sgw.e NAMEC\ PRESENT ADDRESS TEL # CONTRACTOR V.lwl,A mac. ;✓ lt9O wipes 'beck \CA �pee.,-)- SVFS3(o281$1NAME MAILING ADDRESS EL.# Residential 0 Commercial/5-3 -1 it, Est.Cost of Construction S 2. ZO(O�0 O Home Improvement Contractor Lie.# t Construction Supervisor Lic.# V/ 7( 3 Workman's Compensation Insurance: (check one) 0 I am the homeowner 'lg I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: ttkkrj S4. Vk.M v,ce Pg.9vV Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares t (D ( X)Remove existing* (max.2 layers) Insulation 9' �y Led Cechy-6°Red c 10 D, Old Kings Highway/Historic Dist. (K)Replacing like for like Pool fencing *The debris will be disposed of at 11,✓Wn 0 t.t. Location of Facility I declare under penalties of perjury that the statements herein contained are nue 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 y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: l Date: el IJ f U l z t� t ' Appy Signature(or attachmen(((( ( "tic Date: 5 f(o L tApproved By: Date: 7g29 idin:.�:ecial(ordesignee) RESS: 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 0 No r Pa_,' The Commonwealth Massachusettsof g=+=, =E Department oflndustriafAccidents =��1= ��. 1 Congress Street, Suite 100 1,‘i•.-41,----r-- Boston, MA O2114-2017 '3c.�, www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Learibly Name (Business/Organitation/Individual): 'LP... ;H i f Ci . -lc- Address: I (7O 1 ens —.))4c_k City/State/Zip:4/v+ IUU (0)2Isr7 C Phone #: 6e 362 et et, Are you an employer?Check the appropriate box: Type of project(required): L❑I am a employer with employees(Ml and/or part-time)." 7. ❑New construction 2.EI I 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 ❑ Building addition 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 5.0 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? 13. Roof repairs 6.0 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 suck tContractors that check this box must ached 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. ,1 1 Insurance Company Name: W\q.t vk c\ Lo,4 ( A Gd. Policy#or Self-ins.Lie.#: (D q t.((0 429 Expiration Date: .61 . 1„, ,_, Job Site Address: 2- '-( —0,,w c L p , C.‘‘...y J e Z a City/state/Zip: / M tRjo 7 r Attach a copy of the workers' compensation policy declaration page(showing the policy nu ber 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 u the pains and penalties of perjury that the information provided ab ve is true and correct Signature: - Date: Rif I o la Phone#: Song aiciE $tg'(e, 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#: it .• . Information and Instructions Massachusetts General Laws chapter 152 requires all employers 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 ajoint 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, §250(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance requirement of this chapter have been presented to the contacting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es) 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 advisedThat this affidavit may be submitted to the Department of Industrial • Accident 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/license 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 burn leaves etc.) said person is NOT required to complete this affidavit The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia ,e • Commonwealth of Massachusetts Division of Professional licensure Board of Building Regulations and Standards Const`t tt6rt%iipgrvisor I CS-094639 # noires:07/01/2020 KEVIN J FAIL . , : a - 100 HOMERS$pCK R YARMOUTHPORTMA 01�b75t "'; i + Cit Commissioner C/t /tf(fcniltener/e![L4 ciblicAunditseta, Office of Co Isureer attars E Bushn rss Regt.Istior r`? HOME I'IPROVEME,'r CON r ACTOR nA s:� Trie: Individual ExFLsi 111:5:'318 Cavin Fair <.evin Fair 100 Hon ersdocK •---- Yarnou+hport,MA_025;5 f f tlndersecrwy /fir