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HomeMy WebLinkAboutBLD-19-003191 �F.y t Office Use Only • ,g•is 'i0 Permit# . ,;41. i O ..�i '!1: ' 'Amount �J IJP r „ a �f"""".�crd gL —tq-" Permit expires 180 days from q 9 „issue date RECEIVED EXPRESS BUILDING PERMIT APPLIC • ON TOWN OF YARMOUTH NOV 2 6 2018 Yarmouth Building Department 1146Route 28 eul .�,Z P South Yarmouth,MA 02664 El —' 6 at5- (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I© R ty- I.ane - Wet )(kir/10th Mtn, o T 3 ASSESSOR'S INFORMATION: { Map: Parcel: OWNER: Leh Patrers--m io PN—Alts - sq 138,0-3-809 NAME (,, PRES• ADRES TE . # CONTRACTOR:r(j(,ktt)kS G I,; Gor� it, WJ,�IQrM - 8 -36U-83'77 NAME DAESS TEL# Residential - 0 Commercial Est.Cost of Construction S G Soo (tome Improvement Contractor Lic.# I sq-3 77 Construction Supervisor Lic.# I o B CP-7 Workman's Compensation Insurance (check one) ❑ I am the homeowner t I am the sole proprietor ❑ 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 at Replacement windows:# Replacement doors: # Roofing: #of Squares 19 1/2Z ( V)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 011 Cite N.V nicces—EE r Lo tion 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 or revocation of my license and for prosecution under M.G.L.Ch.268,Section L Applicant's Signature: 0 -•4." / _ Date: II ' J-6-/$ Owners Signature(or attachme /— g ���_ l '/ .' , i late: / Approved By: ret `n Date: //O� 6/c Buil. g j�cial(.r designee) /-MAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No - Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts •_,:, �i Department of Industrial Accidents :el= • 1 Congress Street, Suite 100 • .: __4.7 I Boston, AM 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): Al ?elle he 1tLC 6. 13 ictii / Address: trCaPr; `/1/eAl-P r Rd, City/State/Zip:ctyA tmoiliil 44-A 0-66L Phone#: ,e ; • -� Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.. 1 am a sole proprietor or partnership 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. ❑Demolition 10 ❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑ lumbing 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 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 iContractors 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 employees. 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 51,500.00 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 cert,under and penalties of perjury that the information provided above) is true and correct Signature: 1 lfilt- Date: L I . -m—(2 Phone#: SOS —31;Cf.--57317 Official use only. Do not write in this area,to be completed by city or town officiaL 1 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#: • (J52e Wmmontelea o/Q flastadetiefet Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration rvolratIon 184379 01/04/2020 NICHOLAS G.BRADY NICHOLAS G.BRADY 84 CAPTAIN WEILER RD. cy-CC.Care-- SO.YARMOUTH,MA 02664' Undersecretary, --------------— Massachusetts Department of Public Safety ri Board of Building Regulations and Standards License: CS-108927 777 Construction Supervisor NICHOLAS BRADY 84 CAPTAIN WEILER KO-401 SOUTH YARMOUTH MA 02664 7 • c•••••1r. CA_L. Expiration: Commissioner 07/17/2019 •