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HomeMy WebLinkAboutBLD-19-001567 wlllilf IIllllllll ' =) RECEIVED Lii OE YqR . S' 7 o; ySEP 14 2018 vej� �. ` t ) m`� .,,k r EP e t ,de ' Cc EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I Srlt t- la ie • ASSESSOR'S INFORMATION: Map: I (3 Parcel: I ' OWNER v*V1•O Cl.T'S(lel � taNretla NVQ. NAME �..1 Ml t t f) \`jamY It PRESENT ADDRESS TEL CONTRACTOR: tt aVY -\ ( k scot Fcs- W14 NAME MAILING ADDRESS TEL# llttesidential ❑Commercial Est.Cost of Construction$ r3,000 Home Improvement Contractor Lic.# 1314 '1(/e\ Construction Supervisor Lic.# -(.dsL i 0013 Li Workman's Compensation Insurance: (check one) • ❑ I am the homeowner /��/❑ l a`n the sole proprietor 4(lhave Worker's Compensation Insurance 0 Insurance Company Name: M(CV.,l'C Worker's Comp.Policy# t" 00(ro9 SO.11 _ a 3 WORK TO BE PERFORMED 4 Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # • .) � Roofing:I #of Squares /0 ( X)Remove xisting•(max.2 layers) Insulation_ 3 Itis) 'f INliaKings Highway/Historic Dist. (�� Pool fencing �' f"� ‘310-4, � OK 647kjW oo p i Asp/4i. 'The debris will be disposed of et: (NC' ' ps-ex-a Location of Facility 1 declare under penalties of perjury that the Gatemen • in contain • are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will bejust cause for denial or ' a'. of er y a .. pro 'on under MA.L Ch.268,Section I. /4/ Applicant's Signature I (L/✓ �� Date: i Owners Signatu• (or atta ment) ��/�i Date: Q Approved By. G'�td ay DDate: 9/16/U Building Ofrici _;,yTC-) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 0 No • 111111111'14.1111.111 • •_,t • The Commonwealth of Massachusetts • lam e=•etit=C/ Department of InduslrialAccidents • a =pi_ a 1 Congress Street,Suite 100 "• Boston,MA 02114-2017 • 7c,,;�„ 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/lndividual): ROBERT H.CHAMBERS,INC. Address: 102 WHIFF[,FTRFFAVE. BREWSTER,kkai 026331 City/State/Zip: • Phone if. SOK 2c ''1,S4 . • Are you an employer?Check the appropriate box: Type of project('required); ?al am a employer with Z. employees(MI and/or part-time).* 7, ❑New construction 2.1:11 am a sole proprietor of partnership and have no employees working for me in 3. ❑Remodeling any capacity.[No workers'comp.insurance required.). • • 3.❑lam a homeowner doing all work myself.[No workers comp.insurance required.] 9. ❑Demolition 4.01 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 5.0 I am a general contractor and I have hired the subcontractors listed on the attached sheet 13.1:11Roof repairs These sub-contractors have employees and have workers'comp.insurance.t • • 6.0We are a corporation and its officers have exercised their right of exemption per MOL© 14.❑Other 152,§1(4),and we have no employees.(No workers'comp.insurance required.) • 'Any applicant that checks box 91 must also fill out the section below showing theirworken'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such tContractors 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'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. A 6.1114.r. (rV�' --y(_ _ Insurance Company Name: ,eChv Policy#or Self-ins.Lic.#: VICV Ooh 21-4gb I Expiration Date: i /1.1 y� ,y Job Site Address: I s*k /AA h City/State/Zip: 4o 044LD.� 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 punishablebya.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 ce aJy er the p ' and penalties of perjury that the information provided above is true and correct Signature: Date: Z//1.3�� • • Phone#: Soic 111 Official use only. Do not ivrite 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#: r' • ®�• Commonwealth of Massachusetts • Division of Professional Licensure Board of Building Regulations and Standards Constructioo.SVp`1Fv5spr Specialty CSSL-100134 EX�lires: 03/16/2020 ROBERT H CHAMBERIi 102 WHIFFLETHEE AVE BREWSTER V, y 6311 R' `rlfSSSTdOt LS1 Commissioner CA— • 4726 Wowww,,:mea/dE �fla,wac/uwtl3.. citi.eMD>Dx�.`+:a;Apairs&Business Regulation . • HOME IMPFICVEMEH't CONTSACT JR , -TYPE:Suec@rnent Citi 1;,/03;2019 • ROBERT H.CHASI6EAS,;RiC-':". • • SM ROBERT H.CHAMBER 102 WHIFFLETREE EREWSTER,MA 02631'=2-I" ' Undersecretary • • 3k 62.A.Ao4 gez4 • • • The Commonwealth of Massachusetts M_ la WillCl Department ofIndustrial Accidents • 'E MINI1= 5 1 Congress Street,Suite 100 Boston,MA 0211 4-2 01 7 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): • ROBERT H.CHAMgCRs INC • Address: . 102 WHIFFL p�F City/State/Zip: BREWSTF'RN Are you an employer?Check the appropriate box: • Type of project(required): 14.1 am a employer with 2 employees(full and/orpan-time).* , . y, ❑New construction 2.0 lam a sole proprietor or parinenhip and have no employees working for mein S. ❑Remodeling any capacity,[No workers'comp.influence required]. • 3.01 am a homeowner doing all work myself.[No workers'comp.imuritnce required]1 9• El Demolition 4.0 1 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. 12.9 Plumbing repairs or additions S.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.t _ 13.0Roof repairs • 6.0 We are a corporation and Its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] • *Any applicant that checks box II 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 anew affidavit indicating such. tContractors 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 subcontractors have employees,they must provide their workers'comp.policy number. l am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy andJob site information: ����J(( r��(l Insurance Company Name: M-GlWitt \.J C. �f� ctr p . Policy#or Self-ins.Lic.#: WO) Cabet S'o k a Expiration Date: l'• �/ f cR —}� Job Site Address: CCity/State/Lip: O `O+f'-- Attach a copy of the workers'compensation policy declaration page(showing the policy num e mer and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishablebya 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. Mo hereby cert!a .•: / p" a 'a of perjury that the information provided above)true and correct. j3ignafnre: .,.�p Date: ' • Phone#: £04 3/ S t-4Sy�. Official use only. Do not ivrlte in this area,to he 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#: