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Home My WebLink AboutBLD-19-002442 o f'Y &Office Use Only `� - . .01' :-.- ; ! c _ i Perm W qo- -O, 'Yia't, " ,.Amowt ' A -__ .M1,,,;a cud: _ Permit exphes 180,days from . - .- issue daze Z OLD—IG —003LIkfa EXPRESS BUILDING PERMIT APPLICATI k. • • TOWN OF YARMOUTH ' ECEIVED Yarmouth Building Department 1146 Route 28 OCT 242018 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 B u. l�t _i - CONSTRUCTION ADDRESS: 9 yy RT.?P', So uTy yme Mo UTH gaiem;AI a I ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: 967As( PoN 0' Ott) ASSb C . (Pune) Sa8-3g5-44g9 N PRESENT ADDRESS� TEL. # CONTRACTOR: } iC Z.pQ br Jai('Pc- 13 60-/741ti re2gralte SOS 3600213Z- NAME MAILING ADDRESS TEL.# 0 Residential (Leommerciaall9 Est Cost of Constructions 1,0/00'00 Home Improvement Contractor Lic.# /egg 1 Construction Supervisor Lie.# /002905 Workman's Compensation Insurance: (91£ck one) 0 I am the homeowner pram the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: i ye' fleCi 402 7) rl7AePpw 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 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist ( )Replacing like for like Pool fencing *The debris will be disposed of at yinA'`QJi N i.b-. 2 Location of Facility I declare under penalties of perjury that the statement 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 deni. revocation.1 my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 1 ; r . it 10 0 - ;:;�� Date: ��—tG Owners Signa (or attic ment) It�C`1y�.� I s "r6ISA 1 M An A6 E R Date: (e//1.,a 31) 6 / �j /a . Z�•/1- Approved By: � �� ' Date: Building a:. 1.4L. c!_. EMAIL ADDRESS: ' Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 R of Wetlands: • 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts (• Department of Industrial Accidents ^moi_ 1 Congress Street, Suite 100 _11f. • Boston, MA 02114-2017 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers. TO BE FILED WITH TEE PERMUTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):C ZRrz f ML Ccj . A 1 3�g1 Address: '/3 Gap-„,Dft,C1>-2 Dade ” � City/State/Zip: FbRzzbOa9% rt.f al044 Phone#: Sol6 3600213L Are yon an employer?Check the appropriate box: - Type of project(required): 1.0 I am a employer with employees(full and/or part-time).' 7. E New construction 2.®I am a sole proprietor or partnership and have no employees working for mein • any capacity.[No workers'comp.insurance required] 8• ❑Remodeling ur 3.0 I am a homeowner doing all workmyself9. ❑Demolition [No workers'.comp. insurance required.]t 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 contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.0 I am a general contactor 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 repairs G.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other ,710t A/c 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box 411 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 contactors must submit a new a6davit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-coni actors and state whether or not those entities have employees. If the sub-conactors have employee;they must provide their workers'comp.policy number. I am an employer that is providing workers'compensadon insurance for my employees. Below is the policy and job site information. Insurance Company Name: I (I M y7JCf 61 0.242.1A'� Policy#or Self-ins.Lk.#: Expiration Date: Job Site Address: 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 DR for insurance coverage verification. I do hereby fy under the airs and penalties of perjury that the information provided above is true and correct 2a Signature. j "- Date: 10 - 02J1- �jlr 8 Phone#: 5 08 3&o o2'3a' 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: r C-�ii Tl Inntntutrc�'l21C elbenuark JelYl Or a of ConsumerlQfafn Business Regulation HOME IMPROVEMENT CONTRACTOR Type: Ind vidual " Registration Emigration 166919 10/25/2018 Cezar Lanca Cezar Lancs 13 G 13 randwood drive Forestdale,MA 02644- Undersecretary • MassachusettsDepartment blic Safety V Board of Building Regulations and Standards License: CS-102906 Construction Supervisor CEZAR A LANCA 13 GRANDWOOD DRIVE FORESTDALE MA 02644 Commissioner Expiration: 05/11/2019