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EXPRESS BUILDING PERMIT APPLICATI 0 —f
TOWN OF YARMOUTH NOV 08 2018 I
Yarmouth Building Department
1146Route 28 Bui�ICS( <
South Yarmouth,MA 02664 8y. Ste£ do
((5�5//08)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: /SS' ccw1 SA6re,De: S. Slant/wag (011,9.L
-f Z- S-#G-#7 74
ASSESSOR'S INFORMATION:
, Map: Parcel:
OWNER: Y. NAM C. rt•E Stac-44_C ORESENT ADDRESS TEL #
CONTRACTOR: Rcfrit t7bS e0. 60x 311 Y-Poe-r -77y-33-3--I00S1
NAME MAILING ADDRESS TEL#
❑Residential Comers'/ 588sial Qty0 Est.Cost of Construction S 70 29
Home Improvement Contractor Lic.# /6 Construction Supervisor Lie.# Ci S—oBio'yo
Workman's Compensation Insurance• (check one)
0 I am the homeowner X1 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 6 Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. (Ai Replacing like for like Pool fencing
*The debris will is
be disposed of at ) 4 ,I .Seco
Location of Facility
I declare under penalties of perju. that e st: - ents 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 or a7 : '.n o,,license and for prosecution under MAIL Ch.268,Section 1.
Applicant's Signature: // i' Date: //79/do/B
Owners Signature(or attachment) Date:
Approved By/�1/y B - m 'tial( r designee)d AIL ADDRESS: Dom: j/ /
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
I
• The Commonwealth of Massachusetts
�=
Id—--"1 =yt Department oflndustria[Accidents
IC WASH 1
Congress Street,
• _ '�_ Boston, MA 02114- 0
2017
'c., ,s� www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): P0. lacca f
Address: ea 130)c ?IN
City/State/Zip: y Pdf / ,s oaGic Phone#: 77y' 3S3"-•66f
An you an employer?Check the appropriate box: Type of project(required):
1.0 lam a employer with employees(full and/or part-time).* 7. 0 New construction
2..2Lem a sole proprietor or partnership and have no employees working for me in $. remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work myself t 9. ❑Demolition
❑ ys [No workers'comp.insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,11(4),and we have no employees.[No workers'comp.insurance required.]
•Any applicant that checks box#1 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 contractors must submit a new affidavit indicating such
:Contractors that check this box must 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 am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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 DIA for insurance
coverage verification.
I do hereby certi nd the .ains and penalties of perjury that the information provided above is true and correct
Signature; Date: `187l�/I
phone#: 77V- 3 3- re 85`„2
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):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
•
/ ° Conmonweafh of Massachusetts
1111 Division of Professional Licensure
Board of Building Regulations and Standards
ConstrtfettPe"Sopervisor
CS-081040s ^ " Equres:04/04/2020
)� i••
PATRICK H JACOBS f7!. - n
28 N DRIVE ff..'
DENNIS MA 02638
�' _ "1'
Commissioner V'^'
•
i e unnmone raf/A eybilaa0Jawl4
Orrice of Consumer Affairs 6 Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE,1ndiNdual - -
Registration—IN Expiration
165888 4 05/14/2020
PATRICK JACOBS
.,.. __.-
D/B/A P.JACOBS CUSTOM CARPENTRY AND
REMODELING rr€-- " ry
PATRICK S
28WHITTERDR.
DENNIS.MA 02638 ._'---`-::.
Undersecretary
Seaside Cottages
Yarmouth Village Condo Association , ' = : 'f -41• ,_r
The Cope Cod of Yesteryear.. , .,
with a touch of today's conveniences. ""
November 8,2018
To Whom It May Concern:
Pat Jacobs has been contracted to perform siding and trim replacement on our cottages.
Please let me know if you have any questions. ".
Regards,
eanne Bishop
4Z%)
5?it-tst :ji
Property Manager
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