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Home My WebLink AboutBLD-19-002987 _� r . „y� Office Use Only _ u .or a RECEIVED Permidi �' 3 � 9 i O �+ H Amount .�""' ,c? 5241—M.1, Permit expires 180 days from Tissue date t'. BtiILDINu DEPARTMENT BU)-1q �j /��a g� EXPRESS BUILDING PERMIT • ' ICATION 't�V 1 TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 (41t 1CONSTRUCTION ADDRESS: /rr .5a/1t Aere.� S knot:xiG1 �/ASSESSOR'S INFORMATION: Map: Parcel: OWNER: '/.U.C.W. SPR SrSt l/&NAME ENT ADDRESS TEL M CONTRACTOR: Pa 2t--Cla f ob$ PO. e0,' 3Y4( Y-Port 77Y-3f?-&9s). NAME MAILING ADDRESS TEL# ❑Residential Commercialal (�p,�'{ Est.Cost of Construction S /00q Home Improvement Contractor Lia# �i,7se/(/a Construction Supervisor Lie.# es-am o 110 Workman's Compensation Insurance: (check one) ❑ I am the homeowner b4am 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 .2 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist IOCReplacing like for like Pool fencing *The debris will be disposed of at: Location of Facility I declare under penalties of perjury,the gement 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 rev .n; my Ii se and for prosecution under M.O.L Ch.268.Section I. Y/ Lam_ /170)07/1 pplicant's Signature: Date: I Owners Signature(or attachment)) Date: / ��'�� 7 Approved By: /`f ce '•G2i//� —_. Date: /(i Bintfi ' or des' ee) EMAIL ADDr�EliS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Conunonwealth of Massachusetts 8 tdri Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 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): Otfr),K- G d cob 5' Address: ?o. 6O>< 3y`( City/State/Zip:Y tort I vvi 0}475 Phone#: 7741 -75. —GSFr Are you an employer?Check the appropriate box: Type of project(required): 1.0 lam a employer with employees(Ml and/or part-time).* 7. 0 New construction 2.jam a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required] 3. I am a homeowner doing all work 9. 0 Demolition ❑ gmyself[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I wail 10 ❑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? 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No waters'comp.insurance required] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infurr.ration. 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. lithe sub-contractors have employees,they must provide their workers'comp.policy number. 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: 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 cent / er hep/ s and penalties ofperjury that the information provided above is true and correct Signature: I Date: (//97a1/1, 1 7 ' '1 Phone#: 771/— 7 ?" 6 9f,Z 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#: 4. • ®� Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards C o n s t ryletf ti&thi pe ryi s o r 1. CS-081040 ' n• Ejspires:04/04/2020 PATRICK H JACOBS 1'14 y 28 WHITTIERDI:IVE k':? DENNIS MA 02698 lb/sr Nil ,��' Commissioner a. Office of Consumer Affairs&Business Regulation , HOME IMPROVEMENTCONTRACTOR TYPE;lndMdual - . . . ReaistratioR\ E7coiraBOR 165888 , -_ ''05/14/2020 PATRICK JACOBS" 'r= -;�:5 -� D/B/A P.JACOBS CUSTOM CARPENTRY AND REMODELING ' r1` '• `, t y PATRICK JACOBS 1.. 1, " - 28 WHITTER DR '5'� - [� s -..._... i' DENNIS,MA 02638 Undersecretary