The URL can be used to link to this page

Home My WebLink AboutBLD-19-002516 = D-/9-03241 i "0„4_y • i Amount �s]�"+�' P®1t expires 180 days from ,_Issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department ,. . , A •r 1146 Route 28 OCT/1 6 2018 South Yarmouth,MA 02664 _ (508) 398-2231 Ext. 1261 BUIL DI %9RTMENT by CONSTRUCTION ADDRESS: 3E1 V OLer to moi ) U� ASSESSOR'S INFORMATION: Map: 1 Ca Parcel: t OWNER: IcAttriJ •fC Q 54P Soy 73) -ally NAME P?ESENr ADDRESS TEL # Email Address: CONTRACTOR:.-a`-Pm wmu, S4 S(UTtAi sT (t PoMT di-6)V 17Y -353 -6a-7 r,.;,:at2coirtkriertricti4, NAME MAILING ADDRESS TEL# ' Email Address: Rhe d�m�n Commercial Est.Cost of Construction$ 1►,O 0.00 Home Improvement Contractor Lie.# I Y9-n3 Construction Supervisor Lia# 0"ciYia Workman's Compensation Insurance: (check one) I am the homeowner am a sole pro eP 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 / Replacement windows:# Replacement doors: # r� Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Flighway/Historic Dist. ( ')Replacing like for like *The debris will be disposed of at 1 d%MY). l tr CC PA,D Location 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 that any false answer(s) will be just cause for denial/aeon of my license and for prosecution under M. Ch.268,Section 1. Applicant's Sit•....e-• / " Date: {d 17 $ Owners Si-.u, .r- .rasent A f . �/ GA, Date: /O -1a _/8 � - - i or A Approved By /2 .er Date: l) -A S Building Official(or designee) Zoning District Historical District Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No • `-" Alt= a-urnrnonweajrn of Mafsacnusetts g . Department of lndustrialAccidents =1f'nl I Congress Street,Suite 100 _W_7 Boston, MA 0211 4-2 01 7 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH 1Hi•.PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Bysiness/Organizaaon/Individual): LTE'ry 11\-144 4ddress:_ 5 W Clcd�Z�►J c :ity/State/Zip: tH t t' /a 04-7s- Phone#: '7l4 -353 .rc you an employer? Check the appropriate box: - Type of project(required): ❑I am a employer with employees(full and/or part-time).* 7. 0 New constriction �E am a sole proprietor or partnership and have no employees working forme in any capacity.[No workers'comp. insurance requited.] 8• Remodeling❑ ❑I am a homeowner doing all work myself [No workers'comp.insurance required.]t 9• 0 Demolition ❑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 warkera'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. .. m 12.❑Plumbing repairs or additions D am a generalcontractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'romp.insurance? 13.0 Roof repairs We are a corporation and its officers have exercised their right of exemption per MGL e. 14.❑Other 152.;1(41 and we have no employees.[No workers'comp.insurance required.] y applicant that checkm box 41 must also fill out the section below showing their workers'compensation policy information. maeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such ttractors that check this box must attached an additional sheet showing the came of the sub-contractors and state whether or not those entities have loyees. If the sub-contractors have employees,they must provide ter workers'comp.policy number. n an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nutation. trance Company Name: cy#or Self-ins. Lic.#: Expiration Date: Site Address: 311 vic14 f ,W)') City/State/Zip: ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Ire to secure coverage as required under MGL c. 152, §25A is a criminal violation pnnishable by a fine up to 51,500.00 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 against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance gage verification. hereby certify ,er the pains and penalties of perjury did the information provided above is true and correct ter. , Date: /l)-t) y� ne# ffzcal use only. Do not write in this area, to be completed by city or town official :It, or Town: Permit/License# ssuing Authority (circle one): . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector . Other :ontact 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 gmployee 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 ajoint 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." MOL 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 construct 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 certificates)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP 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 Accident. Should you have any questions regarding the law or if you are 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 appropriate 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) and 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 permits 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 bum 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. # 617-7274900 ext. 7406 or 1-877-1v1ASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mnss.gov/dia . .. _ Cl/rrt 1!'ommonuroa�( o`'G� �a acA,'a Office of Consumer Affairsb� Business Regulafttion i HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE;Ind(Ndual before the expiration date. If found returnto: I pealstratloR', )=xoiratiott Office of Consumer Affairs and Business Regulation 149773 02/21/2020 10 Park Plaza-Suite 5170 JEFFREY W RAGG Boston,MA 02116 - LI f JEFFREY L W RAGG \2.G"COr�' 54 EILEEN STREET t d W out signature YARMOUTHPORT,MA 02675 (,Undersecretary Commonwealth of Massachusetts �) Division of Professional Licensure Board of Building Regulations and Standards F Co nstruction'Supervisor CS-075746 u Expires: 09/20/2019 M . .. JEFFREY L W `.RAGG -1• 54 EILEEN S7 ` ' - '-3 rat n YARMOUTH PORT MA 02675 ' ' i iOis T,;Li' .. E S Commissioner c4L