The URL can be used to link to this page

Home My WebLink AboutBLD-19-001569 Office Use Only • • .0V'Y`t4 741 bk. sty 9 `} Permit! IAmrnmt 6 b- (7� Pemrit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION RLp_(q—UvcSb9 TOWN OF YARMOUTH Yarmouth Building Department R E C UA,l E D 1146 Route 28 South Yarmouth, MA 02664 SEP 14 2018 (508) 398-2231 Ext. 1261 7/� BUILDING DiiP;,RTMFNT CONSTRUCTION ADDRESS: /-/ CA( yes �t BY: . ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: SALM Kitovand ?If CAPT vo2?' Soy 74.0 Cvo3 NAME PRESENT ADDRESS TEL. # coNTRAcroRRAttttO 1)VPJ1-014._ I to Su)4i&61QC,(L AhAWP Jt/a SOB 7&? ( 68'f NAME MAILING ADDRESS TEL# Residential 0 Commercial , Est Cost of Construction$ 3 CO - 00 Home Improvement Contractor Lic.# )2902 Construction Supervisor Lic.# DO-11781--- Workman's Compensation In urancec.(check one) 0 I am the homeowner 'H 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 L (Fire Retardant Certificate attached?) Wood Stove , iding: of Squares 7 Replacement windows:# Replacement doors: # Roofmg: #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 ' S'L C SNC • eDEAU )5 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 o oof my license and for prosecution under M.G.L.Ch.268,Section 1. A Applicant's Signature: //%7 ��1j _ Date: y//tike Owners Signa re(or a v chment) r7 Date: 9tl/ti/iT! Approved By: - C t Date: 917- 1/1c Bu •'.aOffici.`:j,. e) EMAIL ADDRESS: 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 Sg • , � � The Commonwealth of Massachusetts _-:- 1-:t Department of In dustrialAccidents !11_ 1 Congress Street, Suite 100 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 Legibly Name (Business/Organization/Individual): /1l fq trgeo - u"JRI , _ Address: 1 (i 6414-111/43 ci ecc City/State/Zip: ii1Vie l MI owe Phone#: sag 3(07 —16(9 Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction ..742I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself r 9. ❑ Demolition ys [No workers'comp.insurance required.] 4.❑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 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contactors 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 MGI.c. 14.p Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box f I must also Ell 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. *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 arrt r foyer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-S.Lic.#: Expiration Date: Job Site Address: is/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the ..:_ .umber and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a u. 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 . '150.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for ins .. coverage verification. I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct Si nature: Date: Phone 4: cOe 367 ) 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#: m lg.f6uae%ruetn il 1e yonsume `y . Office of Consumer Affairs 6 Business Regulation I • HOME IMPROVEMENT CONTRACTOR TYPE:Individual R ai- °'. 0511 125982- _ . MATTHEW M.DUNHILL `--_ I MATTHEW 6SWAIN CIRCLE M. HILL MASHPEE,MA 02649 Undersecretary Commonwealth of Massachusetts ®( Division of Professional Licensure / Board of Building Regulations and Standards Con st`+Ltio?tItdp,rvisor "-; tyires:07/0312020 CS-064962 �1'''. ' F - MATTHEW MAUNMILyi, % 16 SWAINCIR% a`, � t �a � MASHPEE MA _ . 07649 - . a� •ttn!sSQIlia%.11 -rtiii' Commissioner . `t