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Home My WebLink AboutBLD-19-002984 �, gOnce Use Only 4 Pt qR � e �o RECEIVED ggFF k S PetmiW i. O - � 4l Amount q� 1 H%„,�"S g I T .'�Permit expires 180 days from 'k issue date \ NT Bth—Iq _��q '` av � EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 / (508)398-2231 Ext. 1261 ��yy . CONSTRUCTION ADDRESS: /3S50CJ/V1I S�(7t ° pr S. Yttnt'tO1. r1// (unit # 3° ASSESSOR'S INFORMATION: �/ Map: Parcel: OWNER: / . 'J•C. n. gSIdt co-H-44ex NAME PRE NT ADDRESS TEL # CONTRACTOR: PATTtr P Sctcobc to. >R3ox -31414 Y-Puff- '771-f-3s3-60E3Sa NAME MAILING ADDRESS TEL# ❑Residential Commercial Est.Cost of Construction S /00I, Home Improvement Contractor Lic.# I (aSBeS Construction Supervisor Lic.# es— ea/olio Workman's Compensation Insurance: (check one) 0 I am the homeowner XI 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 .5— Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. xReplacing like for like Pool fencing 'The debris will be disposed of at: Location of Facility 1 declare under penalties of perjury that 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 or revocati f tic se and for prosecution under M.G.L Ch.268,Seaton I. Applicant's Signature: Date•. /0?7a-0/8 Owners Signature(or attachment) �� Date: `//} Approved By: / at / - Date: /�/✓//C Bu . g 0 / al(or•csignce) E ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 0 No • The Commonwealth of Massachusetts Department ofIndustrial Accidents s ti miff Congress Street,Suite ''�= t, 1 Boston,MA02114-20170 •a�.�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): 120.-k Ct. TCZLO Sc. Address: P0, Lox 311q City/State/Zip:Vac-MCO/t�aort, Wl Pr 03&7( Phone#: 774(-3S3 e es-a Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).' 7. 0 New construction 2 SI 1 am a sole proprietor or partnership and have no employees working for me in S. JM Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself r 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contactors to conduct all work on my proPmY• I will 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.❑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, 1(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. 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 ant 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.1k 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 certify 54d the ,ains and penalties of pedury that the information provided above is true and correct Signature: 7I/ Date: //'/3/arte Phone#: "�7tf- 3 ' _ u6c i 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#: • Comnonweaof Massachusetts • 1:1; Division of Professional Licensure Board of Building Regulations and Standards Constructlbn tUpervisor CS-081040 < ""' E's ires:04/04/2020 PATRICK H JACOBS r'": i 28 WHITTIER DRIVE DENNIS MA 02658 4 r J~ - Commissioner • C520%104 10101fada jC Ifaa nn(ah Office of Consumer Affairs&Business Regulation : HOME IMPROVEMENT CONTRACTOR TYPErindMdual Recistratloh=A btolratioR "r 165888 t --:05/1412020 • PATRICK JACOBS ; --- D/B1A P.JACOBS CUSTOM CARPENTRY AND REMODELING ' W PATRiCKJACOBS I 28 WHITTER DR. 62-C69.11---1 ... ._. ' DENNIS,MA 02638 Undersecretary