HomeMy WebLinkAboutBLD-19-001600 • r k•Office Use Only
- P:,Z.4 Permitil
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�e111�1 � $ i Amount ;
�a ' c Permit expires 180 days from -
Imo : a date
suf -tqq—oDI(obD RECEIVED
EXPRESS BUILDING PERMIT APPLICATI
TOWN OF YARMOUTH SEP 17 2018
Yarmouth Building Department mo • FAL>*
1146 Route 28 By: ._ •
South Yarmouth,MA 02664
/,/tom/ (508) 398-2231,Ext. 1261 /
CONSTRUCTION ADDRESS: / / • 'R i1 ).-4 Of S per/i1 k(/, kbyin o wl i/ Pi ti 02 673
ASSESSOR'S INFORMATION: �y /�/�
Map: Parcel: / 27- 7J 5- 7075
OWNER .. 001 / ' U' A __i -, i_ 0 / I: /% f/ . / / //
NAME PRESENT Is'4• SS If O Z(I'OJCONTRACTOR: C yrloffi/a(/ G3UahSt4rsc� pnrC6-776 ?6
NAMAILING
/Residential
0 Commercial Est Cost of Construction$ 3/47C70 e Q o
Home Improvement Contractor Lie.# //97/it,p Construction Supervisor Lic.# n 92 53 7
Workman's Compensation Inssurance:,(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#
I WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 8 Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Icings Highway/Historic' Dist. ( )Replacing like for like Pool fencing
`The debris will be disposed of at 7 inneviM V/s Avcsn/ Seer
Location of Facily)C
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 revocat of my 'cense and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: , e OC�T� Date: % 7-
.Owners Signature(or attachment) �F�/ 1/�/,( / ,i, 1 '1/// Ili.. s ate: 9 /� v a o/O
Approved By: / -—li/n�Li / Date: p-7,7-78
Buil..e a r'gal(.r designee) 41 • s 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:
❑ Yes ❑ No ❑ Yes 0 No
'4'',,.
• The Commonwealth of Massachusetts
y Department of Industrial Accidents
Mrs _ ) 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): P-4(4 rho TIM in-0
Address: 203 (I nio St
City/State/Zip: /Yfryliw kfc>"/' /11q Q7673-Phone #: 5-Per'7 6 - /163
Are you an employer?Check the appropriate box:
Type of project(required):
I.D I am a employer with employees(full and/or part-time).*
7. 0 New construction
2 '!am a sole proprietor or partnership and have no employees working for me in
• 8. Ei Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all workmyself t 9. 0 Demolition
(No workers'comp. insurance required.]
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.
12.0 Plumbing repairs or additions
5.❑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.E Roof repair;
6.0 We are a corporation and its officers have exercised their right of exemption per MG!.c. 14.. Other 1574
152,§1(4),and we have no employees.[No workers'comp.insurance required]
'Any applicant that checks box Ni must also fill out the section below showing their workers'compensation policy information.
I.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 subcontractors have employees,they must provide their workers'comp.policy mmmber.
I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: ` Expiration Date:
y
Job Site Address: / /iq jjf4 o pj fld9 4 City/State/Zip: W/,Yarin0 a11A 02673
Attach a copy of the workers' compensatio 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 underdethe pains and penalties of perjury that the information provided above is true and correct
Si�laiure: t doh Qr(/ Date: `-17-/O
Phone#: rat— 7 0713
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#:
•
Commonwealth of Massachusetts
I®f Division of Professional Licensure
•
// Board of Building Regulations and Standards
ConstrOeCt +tilpervisor •
E'y�ires:06/10/2020
CS-042539 <7 a�—Ifr j ,:';,
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CHARLES J MAURO • i .: -`. w'
203 UNION St:, ;'" / c
YARMOUTH P6�T MA 02675 \s �,,; I';,s;
‘OisclACCSCommissioner •
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CHARLES J.dtAtIRO _„-- c12 --
203UNIONST "'%