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HomeMy WebLinkAboutBLD-19-002434 r .• 1Sr Office Use Only ,i PernriU Amount 60 z•"^'• c-'9 Permit expires ISO da)s from '"'., agoof Issue date EXPRESS BUILDING PERMIT APPLICATION RECEIVED TOWN OF YARMOUTH Yarmouth Building Department OCT 24 2018 1146 Route 28 South Yarmouth,MA 02664 �� T / (508)398-2231 Ext. 1261 By: �� CONSTRUCTION ADDRESS: .35-ct"i'IDW I Bjai}- Ici_DaLi y ASSESSOR'S INFORMATION: • C/os Map: Parcel: /�,r� OWNER: J. GAVDelI 9.S Wi((okA) sr c 3/ a cel 339-1-- NAME ./ PRESENT ADDRESS TEL# CONTRACTOR: HOMP 1Ct'4 ... A U '. I' er , • S. Co bY2 Se!1 / NAME M ILI GAD NESS Tr:L 1'943°e=`r3° 80 01st Jul1 tars, earn3Trdit4 IY1 KRResldenttal 0 Commercial Est.Est.cost of Construction$ 0 Home Improvement Contractor Lie.#,1 '2 f (f7 Construction Supervisor Lie.# t^S-oacil Jam? Workman's Compensation Insurance: (check one) C I am the homeowner ,g 1 am the sole proprietor 7 I have Worker's Compensation insurance Insurance Company Name: Worker's Comp.Policy/1 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate ottttached?) Wood Stove Siding: #of Squares Replacement windows:# O• 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:`lUR..NIC 1�+')St 5("/41"I ot3 Iomtlon or Faculty I decline under penalties ofperjury that c statnnena herein contained are late and correct to the best of my knowledge and belief. I understand that any raise answer(s) will be just cause for denial or r- Inc? of my Ike se ay r prosecution under MO.L Ch 268,Section I. s J Applicant's Sip/mart / / I ALA Date: /10 a7 — 2C/ Owners Signature for attach eat) WOW. _ Date: ,Dq a3 Dal? rr �, OC'r Approved By: ,/! _�fDate: /0 ''-ace-718 tax(r - sal for signet) .EMAIL AD -'5: .. ._.. . Zoning District: I llstorical District: • Yes : No Flood Plain Zbne: Yes No Water Resource Protection District: Within 100 R of Wetlands: Yes No Yes No ._ I . , lur081431$100MPS 001/2AJON Amenstopurf --If'KS'.,-°. LivTavlivrial0"2"0a —4,777? slim y agate MNI COO 3.5VO AO SISTIVO3dS 4,121113A011.11,113rION CIL ISMIIIS.Mid'ad ot , • - SLOing./01 i II:.:41,-+Want uofigelriestl elmilanil Pm tilOW 20,40.000 10 10010 IRSERIn Viatagaili a Iania.pagg in fielluldx•ull.M.; 401011XlaradJUI. Ape OW.iMMAIPUI401 Rita 410084816IgIt 4301.111110)001.N3P3A08.1.5 391011 ilogesiboy•••••••••smelt•Inwm.:01a Ile010 Weir's',t).Arnnoa.V,li., "WAS UMW*PIMA(-2WTI LieltioniOpun 0-2-prt4 ..4(.I'.- P:0•164 otIor Sum vie tows • : _ZDNI931101.1 NOL-WØ4 04.13.010s-mid sad el, 81.0242110 SIMISV,. ' noWilloagg entitle pa&VW mostswo p sag* UCIalEIPM 11/50:11:FM 0,1, xli°NOW Puna)*'NIP UOIMIdxli ma 11400q 4J011n IdeviAtoulai nflureassmiani % 1 SOLOVILINOOJJant5Otiall 31,30 sompionvontsisne v wow immtnewo pea= ''.akt---,tI ;'.' ------- . _SenhODISVITAWM 0I0A trnilniOnUi 1400.0n Sd0 "OtIODO+NIP 00511000dd 101 arm SI apn Sutpuris WM asasstromil•CIP U04110•104ar0 1,1111MIOCI CI*Mel wads pasopue P(01000ISI00,tee)Pal f0n0 000Ve inn ni0 t00300,Pp"Cli10.18*Si,Ma ID Sflutpre-papwsejun :04 041CW•Itl . 106*.socInS uofpfuls000. .., anal= tomo4ss004000 :uopeirhg -no:c.c-ki ,,--- -:=., wan VW SINNVAN _ .4- tiVI 't,17,-,•,,IZ. SU&X01104 Dona ri MI' kosinadAS 000-IlutSo00 • 2 WaSSO-S0 1400on • slanculeIS pus su00110500 ISuIPL018.10 10009 it 4.0s.,,nd 104u004mIlaCI taism.lveneN1 • ,... 'a 1 . . v __ The ComrreonwealhojMassachusetts i�g""'—E. Department of Industrial Accidents alio• r _ l_ a 1 Congress Street,Suite 100 _ If =a Boston,AM 02114-2017 ,,..„,-L,o" www.mass.gov/dna Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITI', Aaaliant Information 1/ Please Print Le_ibly Name(Business/Organization/Individual): /ewe iMQroieMenj cferaf:tis of'CaPe eoel Address: Po ©!c) Ina Cane_ City/State/Zip: ilia enskith' 1‘11A 0263° Phone#: SOP ?7/ 2915 An you as employer?neck the appropriate box: Type of project(required): 1.01 em a employer with employees(fuaand/or parttime).* 7. D New construction am a sole proprietor cc partnership and have no employees woridng for me in 8. O Remodeling ens'capacity.(No workers'comp insurance required.) 3.0 I am ahomeownerdoing as work myself[No workers'comp.insurance required.]s 9. Demolition 4.0 t am a homeowner and wilt be hiring contractors to conduct ell work on my property.t will10❑But7d ng addition encore that all connectors either have workers'compensation Innvome or are sole 11.0 Electrical repairs or additions pmpdetonwth no employe. 12.0 Plumbing repairs or additions 5.0 tam a general coitictw and I lava hired the sub-coitactors listed on the attached abed. 13.0Roof awn These sub•carmatlve esbaemployees and have workers'comp insurance., `e �Wy, Owowl'6.0wean.corporationandlesofficershaveexercisedtmarightotexempdonperMOLe. 14• Other tir hell 152,11(4),and we have no employees.[No workers'comp insurance required.] *Any applicant that cheeks box al must also fill out the section below showing their workers'compamadon policy infbrmatioo. t Homeowners who submit this affidavit indicating they are doing all work end then him outside contractors must submit a new affidavit indicating such. ,Contractors that check this ha mast attached an additional sheet showing the name of the subeonharmnend eta whether those entities ban employees. If the subaonbaaors have employees,they must provide their workers'comp..'lie/number. I am at employer that Is providing workers'compensation Insurance for my employees. Below is the policy andlob site tnformadon. Insurance Company Name: Policy#or Self-ins.fL�ie.#: Expiration Date: Job She Address: 1 ' frufIIQw $theei City/statealp: Ail not h 0174o2IdY 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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA fbr insurance coverage verification. Ido hereby u er theajs and enaltia- of perjury that the Information provided aboverlit true and correct. $isnature: �le-� p4 �(Zy� / Date: /fl I/y/ IP phone 0: So? /7/ - 91.i 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#: •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 a joint 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 cbnstrnct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting 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 then the members or partners,are not required to carry workers'compensation insurance. If an LLC or LIP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial • Accidents 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 ere 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 t.,,m. 'ate 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)end 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 permit 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-MASSAFB Fax#617-727-7749 Revised 02-23-I5 www.mass.gov/dia