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Home My WebLink AboutBLD-19-003264 Office Use Only r_! O` Permit(' G ' O ��'�' . $Amount 5, .l Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION EC � �� TOWN OF YARMOUTH E C E I V E �+ Yarmouth Building Department 1146 Route 28 NOV 28 2018 South Yarmouth, MA 02664 BUILDING DEPARThi NT !j Met) 398-2231 Ext. 1261 Lit CONSTRUCTION ADDRESS: /0 CA f fMet) yaiK • ASSESSOR'S INFORMATION: • Map: �3.! Parcel: Tith CRI OWNER: lam .Vd 90 . Iv et sot 974 141// PRESENT ADD SS TEL # CONTRACTOR: Nat/ TO/Mat a# Sag/rte/eCit M4sifi Se* 367 l bgL f NAME MAILING ADDRESS TEL# Residential 0 Commercial rn Est.Cost of Construction$ 7000• et) Home Improvement Contractor Lie.# I ZS /gt Construction Supervisor Lic.# ()(P�7r>t Workman's Compensation Insurance: (check one) 0 I am the homeowner • 1$•I 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 q Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( ))RReveppllacing like for like �Poolol�fencing 'The debris will be disposedSZ G'of at a /he. 5' " YUVINc Location 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 revocc�/of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /�*7it) AJ y/��" Date: i i/ZICher Owners Signature(or attachment��j ..C/ ! J/4� "Date: �)/ / �g Approved By: Date: ��`��--/6)--/6)ff Buil.',. • .'-:, (ordeysignee) /ADDRESS: n)uNLa 140L.• CQitf Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No ' ✓ • The Commonwealth of Massadhusetts —*no y_ Department oflndustrialAccidents worm 1 Congress Street,Suite 100 =1411-0--- ••*. Boston, MA 02114-2017 "kt�. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /, /4), Please Print Legibly Name (Business/organization/Individual): �4it( 1)c.4Vl(IL-L Address: ((D ;KM,/1/4) CiettE City/State/Zip: M45X , MA a%4' Phone #: SOO' 347 JlaB"ft 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. E New construction 2 am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling eery any capacity.[No workers'comp.insurance required.] IQ I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring 10 E Building addition contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 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 o. 14,,E Other 5.1 /Nir- 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. :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 employees. Below is the policy and job site (Ui ormation • - Insuranc Name: Policy#or Self-ins.Lic.#: _ Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the work- _ ompensation policy declaration page(showing ii -. is number and expiration date). Failure to secur- :•erage as required under MGL c. 152, §25A is a criminal violation punishable .' . e up to$1,500.00 and/or .•- ear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine o . • '•'150.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insuranc- coverage verification. I do hereby certify under 'the -pains and penalties of perjury that the information provided above is true and correct. Signature: 92/1k11C,JI/l.(.et�( Date: 11/241q Phone#: F00367—'6/84 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#: • • 1 Commonwealth of Massachusetts 11 Division of Professional Licensure 1 ! Board of Building Regulations and Standards Const\tdctidn'SUPgrvisor CS-064982 _! E9ires:07/0312020 i `. MATTHEW M-DUNHILL'i-T //! 16 SWAINCIR% re�r/• MASHPEE MA 01649 •gcs:i At bath Commissioner V'"" cfie"Fanernonuweu/(Arsbe�r'fiewarAulef(3 HOME IMPROVEMOffice of Consumer ENT CONTRACTOR Business Iaa TYPE:Individual - RReclstration l xolratlon 125982 05/13/2020 MATTHEW M.DUNHILL 11 MATTHEW M.DUNHILL /` J 16 SWAIN CIRCLE U MASHPEE,MA 02649 Undersecretary