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Home My WebLink AboutBLD-19-002486 • Li: Only `A -� orti '.fkt�� ,; tiva+w-s;: c days from EXPRESS BUILDING PERMIT APPLICA WEir C E I V E D TOWN OF YARMOUTH • Yarmouth Building Department OCT 22 2010 1146 Route 28 South Yarmouth, MA 02664 BUIL ear4 g'11I ENT (508) 398-2231 Ext, 1261 9y_ — CONSTRUCTION ADDRESS: 33 Fe r 6" 9 (' f rJ `C L/J ASSESSOR'S INFORMATION; Al,, 1 1 H] Map: . �(o Parcel: 477 owNnn: ATv",-ire 13 10 6-reajci,vF t'/" 2o/ - 90- 3(1it- NAME PRS ADDRESS / TEL 8 R J v 1-4CONTRACTOJ k5 err' 10 2 Low b e C.o t,t.)171 sot — 5111Pe�WD -- O I f7 NAME MAILING ADDRESS < TEL a 07jh 0 Residential 0 Commercial Est.Cost of Construction S 7 �t q [tome Improvement Contractor Lie,N !) 3 7 g "s)� Construction Supervisor Lie.# 09 SO'. & I Workman's Compensation Insurance: (heck one) 0 I am the homeowner /ryl am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# , WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares / a Replacement windows:# i 2. Replacement doors: # Roofing: #of Squares ( )Remove exlsthig•(max.2 layers) Insulation Old Kings Highway/Ifistoric Dist. ( )Replacing like for like Pool fencing j y1 4 ',The debris will be disposed of at yl4 / M -{o, L —re a Ns ct`1 Si-d44. Ion / Lousloe 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 then any false answer(s) will bejust cause fir denial Of - tion of my license and for prosecution render M.O.L.Ch.268,Section I. I 4)3 Applicant's Signature: /r Date: /o / /g(2 °� 425 Owners Signature(or atrocbmenpate: t O -. t 1 - I Approved By: Date: �� /0 --,2G'lg B " ng e--cial a designee) ADDRESS: vs A N cA..c.4..,...r.j EA eiN gill 0 f:r ZoningQistrich - C ere"- Historical District: 0 Yea ti Flood Plain Zone: CO Yes je No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes pr No 71 Yes R No . The Commonwealth of Massaihusetts • tZ__,;reit Department oflndustrialAccidents • :4, ;fa 1= I Congress Street,Suite 100 i tr Boston,MA 02114-2017 • ,,;=r�r° www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TEE PERMITTING AUTHORITY. Applicant Information Please Print Lexibly 'Warne (Business/Orgenkation/Iodividual): t ) ON -DE1;'1J Address: 10 1- Lows r Eau r Ay tae City/State/Zip: fA-I M c b h,_. MA- oa Phone#: • Are you an employer?Check the appropriate box: Type of project(required); 1.01 am a employes with employees(full and/or pan cmc).' 7. ❑New constriction 1 rW�(I am a sole proprietor or partnership and have no employees working for me in B. remodeling any capacity.[No workers'comp.insurance required.) J • 9. ❑Demolition 3.0 I am a homeowner doing all work myself[No worker'comp.Insurance required.]t 10❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct an work on my property. I will ensure that all contractors either have wodars'compensation insurance or are sole 11.0 Elecaieal repairs or additions proprietors with no er ployees. 12.0 Plumbing repairs or additions 5,❑I em a general contracnr and/have hired the aut.-contractors listed on the attached sheet 13.0 gnof repairs These nub-co trtebn have employees and have workers'comp.hnurance.t 60We area corporation and Its officers have exercised their right of exemption par MOL 14.0 Other I 52.§1(4),and we have no employees,[No workers'comp.Insurance required) 'Any applicantthee cheeks box ill must also fill out the section below showing their workers'compensation policy inforrnetion. r Homeowners who submit this affidavit indicating they axe doing ell work end then hire outside contractors must submit a new affidavit indicating such tContiacmq that check this box must attached an additional sheet showing the risme of the sub-contractors and state whether or not those entities have employees. If the sub-contractor&have employees,they must provide their workers'comp.policy Dumber, I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 'R3 ?t fi r.t.t $. I-Al City/state/zip: 5•� YAA-mow -ern s Attach a copy of the workers' c pensatlon policy declaration page(showing the policy number acid expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to S 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 under the pains and penalties of perjury that the information provided above is true and correct iDate: /D� I�? ' IB t Phone#: 5-O8 Z(01Z — O7hpj Official use only. Do not write in this area,to be completed by city or town offrdaL 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.Otber Contact Person: Phone#: OF•`..9p ]Office Use Only yte C ,Rermite • to ...;;, 4. ?amount ID,Mw.a�- -a Permit expires ISO days from • issue date EXPRESS BUILDING PERMIT APPLICATION , TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 T (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 23 Fere- 9 ( I/J tc L hJ ASSESSOR'S INFORMATION; / Al ( f / Map: , 2-Co Parcel: ti 3c OWNER; / ' /8-1-1 VArISC o Ii Frit clnlG L'N 20( — 90— 3411- NAMEPRESgJCADDRESS / TEL 0 CONTRACTOR: Jan) 17'5 A'r'1 ' I Z 2 l eo w& r ( D v P-147 p,q 50? - tatog — o7 6 ( NAME MAILING ADDRESS TEL# D Residential C Commercial Est Cost of Construction S Home Improvement Contractor Lie.# I i 3 7 R 11 Construction Supervisor Lie.# 09 502. 69 Workman's Compensation Insurance: {;heck one) 0 I ant the homeowner di am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: / Worker's Comp.Policy& WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares I a Replacement windows:# (2- Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Ilighway/Ihistoric Dist, ( )Replacing like for like Pool fencing • [ j 'Ihe debris will be disposed of at VA / M o,-1 1, -Tf A'N`f + f l S�A� t ct/J / Location of Facility I declare under penalties of perjury that the statements herein contained an 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 ova tion of my license and for prosecution under M.O.L.Ch.268.Section I. / Applicant's Signature: Date: /0 Ji S 12 °1 3 Owners Signature(or attachment) I/1+n'. P�_r.. Date: io — I2 - I`S Approved By:, Dale: Building Official(or designee> EMAIL ADDRESS; 1 Vs A. >,'Ib-- Zoning Istria: c , Historical District: C Yes t No Flood Plein Zone: C Yes f No Water Resource Protection District: Within 100 ft of Wetlands: (? Yes f/ No 0 Yes g No ; � � The Commonwealth ofMassachusetts • u5 jitt tt Department oflnduslrlalAccidents .111S =1 1= a • I Congress Street,Suite 100 1=s� Boston, MA 02114--2017 . `*�'MO. www mass.gov/dia \Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO SE FILED WITH THE PERMITTItgG AUTHORITY. Applicant Informatlpn Please Print Legibly Name(Business/Orgenization/Individcal): JON ,1/E/3-r`] • Address: I 01- Lowt r Cfsv r•Ay 2d( City/State/Zip: �1 A-/Moi. 11- MA- Oa Phone #: Are you an employer? lCheck the appropriate box: Type of project(required): lO 1 am c employer with employees(full and/or part-time).* 7. ❑New construction I am a sole proprietor or partnership and have no employees working forme in 2. n any capacity.[No worker'comp.insurance requited.] 8. 2'Remodelina 3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will10 0 Building addition ensure that all contractors either have workers'compensation Insurance or are sole 11.0 Electrical repairs or additions propriemrs with no employees. • 5.❑I am a general contractor and I have hired the sub-convaceora listed on the attached sheet 112.0 Plumbing repairs or additions These sub contrecros have employees and have workers'comp. nsurances 3.0 Roof repairs 6.0 We are a corporation and its officers hove exercised their right of exemption per MGL c. 14.❑Other 152.'1(4),and we have no employees.[No workers'comp.insurance required.] *Arty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indie:dog they are doing all work and than hire outside cormactom must sobndt a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the coma of the subcontractors and state whether or not those entities have employees. If the nub-connectors have employees,they most provide their workers'comp.policy member. I am an employer that is providing workers'compensation insurance for my employees Below Is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Liu.#: Expiration Date: lob Site Address: R3 ?t i r l."-J -- 1../,/ City/State/Zip:_S* 1e a In°CILAl A- Attach a copy of the workers' c pensation policy declaration page(showing the policy number acid expiration date). Failure to secure coverage as required under MOL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,es 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 c ' under the pains and penalNrs of perjury that the information provided above is true and correct Signature: ( Dale: l a- I b - J B Phone#: '5'o 3 r 2-65q — D'4.) Official use only. Do not write in this area,to be completed by city or town officfaL 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#: . f 1 45,10 9 5 rf ., x 45P Biceof Consumer Am t , .a , q HOME IM PP OVE MM E C R e.- P 4 e istIat. en txct a �� c gde 17'-`-c72.4. p _ I1 _fa } -. i a7.1-7 4 "'E , • Sent from Yahoo Mail on Android On Mon, Oct 22, 2018 at 9:52 AM, Cipro, Linda <Lcipro@yarmouth.ma.us> wrote: Good Morning, I've receive the permit application for 33 Peregrine Lane. Please submit copies of your HIC registration& Construction Supervisor's license—both have expired—and the permit fee of $100.00 in order to issue the permit. Thank you, Linda 3