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Home My WebLink AboutBLD-19-2711 i- Uselhnly cit YgR"r !f 4rt �5 coa Y. 11 „N4 �4' jAmount -- yw/ t -$J,"�,��'”'=`�` l Permit expires 180 days from i J issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department • 1 146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I , IOU VJ t".vksfry(etwa3k -I. QWT3 ASSESSOR'S INFORMATION: Y Map: Parcel: • OWNER: . UUCn,A I,O ICs/\ 30 Roc)<x vngkat-Z AAA tAk54-S4:2k'x' (nit Pt. oz(3z_ NAME4, 'J.ItESF.'N'r Af,$JFsf t.l i TEL x CONPRACTOR:K(, vt r, clt,, t,et,`tti 0114- P ?7y f Srzq NAE MAILING ADDRESS TEL a Diegidential 0Commercial • list.Cost of Construction S S.rpZC/Y2 Home Improvement Contractor Lk.H ( '4&& C/7 Construction Supervisor Lie.M f `t l 571 Workman's Compensation Insurance: (check one) U I am the homeowner 2 I am-the sole proprietor 'i: ave Worker's Compensation Insurance " ,� Insurance CompanyNt me:� itrALI iNA�t0''C Worker's Comp.Policy# 2031 3(43 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors# Roofing: #of Squares (6 ( t/Remove existing`(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: it Location 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 m revocation of my license and for rosecutlon under M.OL,Ch.:68,Section I. Y Applicant's Signature: t Date._0141117 Owners Signature rattach ent)�// �/ Date: �� it ¢` Approved By: ', /.7"..,...141."5 _ Due: lI ' S-- IO Building Officio AVOW EMAIL ADDRESS: LLL� Zoning District: �. I V E D Historical District: : Yes ) C'No Hood Plain Zone: Yes C No R E Water Resource Protection District: Within 100 ft.of Wetlands: �iJ C1 Yes G No Yes ! No VO f" 5 22011B 801LDWG DEPARTMENT 9V �� The Commonwealth of Massachusetts ., 1>0'—=111W.fit Department ofIndustrial Accidents • h 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass cov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �, Please Print Levity Name(Business/Organization/Individual): 1Cctte_ a-tzinn Address:4-(dp 1Ftn,deret'SZI OA( `zGQ City/State/ZirL .Avno) t44. OT-C7ia Phone#: '77C $aro•,S_S Are you rrrygggmemployer?Check the appropriate box: Type of project(required): t.❑l a ....eeee''' mployer with employees(full and/or pan-time).• 7. 0 New ew construction , am a sole proprietor or parmership and have no employees working for me in 8. ❑Remodeling any capacity.(No workers'comp.insurance required) - 3.0 I am a homeowner doing all work myself.(No workers'comp.insurance required.)t 9. 0 Demolition 10❑ Building addition 4❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contactors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑PlluuI}bing repairs or additions 5.0 1 am a general contract. and;have hired the sub-contractors listed on the attached sheet. 13.n.r Cf repairs These sub-contractors have employees and have workers'comp.irsurancat 60 we are a corporation and its officers have exercised their right of exemption per MGL e. 14.❑Other 152,11(4),and we have no employees.No workers'comp.insurance required J ~ *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy inform:Mon. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such *Contactors that check this box min attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. f� Insurance Company Name: Swl antat (apt.& �1 lln ivle�' CC'• 9ryj4 Policy#or Self-ins.Lie.#:72f f, 3 6 Expiration Date:leiZe ici fes. Job Site Address:U laK2Q� City/State/Zip: OZC3_3 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 DIA for insurance coverage verification. /do hereby certify under the pains and penalties of peijury that the information provided above Is true and correct. Si ature: -4/d Date:1Il415 phone#: 77t1 S3f 533 'C 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 • ., Division of Professional Licensure r ./ie. n„n rn.vw irr7./pin . /40.43 • Board of Building Regulations and Standard& Office of Consumer Affairs&Business Regulation _ Constrlfcti6r{!Sapp:Visor HOME IMPROVEMENT CONTRACTOR / TYPE Individual . CS-094654 tij !., E Aires: 11/11/2019 - Registration Expiration a' 1 384667--f-f'--4jj 02/22/2020 'Li KYLE A MARTINa - iii,. KYLE A MARTIN 1 r � lr t �1;I 466 BOXBERRY HILL RD /t r ° �; 1 Id EAST FALMOUTH MA 02536 -s• \ .,.r3t�..,,.. ✓. � . . _ KYLE MARTIN _; i� 466 BOXBERRY HILL f1O '•. C2". -EAST FALMOUTH,MA 02536 Undersecretary Commissioner /l 2".