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Home My WebLink AboutBLD-19-003560 o y DEC 12 2018 HorpFe_use -.Tr' )3^;,U . x _ � i�. _�,....__ �. _BUII DING DEPARTMENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 �J1 CONSTRUCTION ADDRESS: I q1 �RIC J'p' \ g bac' Rae) J f R t t 4 rat ASSESSOR'S INFORMATION: Map: Parcel: OWNER: s��id�efl ROTA /'l7 7ha7 tor( 56(ts LI, -5o1,- 347— P5r NQ.?[.}�T/eD PRESSENT AD/DRES /�,�/� TEL # p U q CONTRACTOR: 1[ \T L J, CM 1th 60c 3b 1 UMm'iy]J,Di*Ii `-I/71 Cog-ago - 7 r NAME MAILING ADDRESS `� TEL# *Residential. .. , 0 Commercial Est.Cost of Construction S SS CO Home Improvement Contractor Lie.# I SD?CO Construction Supervisor Lae.# 07i) 6 Workman's Compensation Insurance: (check one) 0 I am the homeowner *'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 Replacement windows:# Replacement doors: # Roofing: #of Squares 7 ( V )Remove existing*(max.2 layers) Insulation VOld Kings Highway/Historic Dist. (Y)Replacing like for like Pool fencing T *The debris will be disposed of at: I c7o IIMILA 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 bejust just cause for den' . ocation of m}license d for prosecution under M.G.L Ch.268,Section I.. fm Applicant's Signature: \JyW{/tl_/yhl/. Date: 7 lo ig �y Owaen Signature(or attachm kilts W yy Approved By: .' l Date: /2—/G/re amidi,_ a ficial(or designee) EMAIL ADDRESS: 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 Massachusetts Ct Department ofIndustrial Accidents Congress Suite • ' ' z� I Boston, Mel 02114- 2017 100 Y www.mass.gov/dia \Yorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): peter s �, c(91 Address: PO atij( Sc 3nc tfavit.N.l City/State/Zip: CoJtt'jn1191 t)i� /` t ' , &b37 Phone#: 5'07- 0220- Y93r Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(foil and/or pan-time).* 7. 0 New construction 2.e I 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 aa homeowner doing all work myself No workers'comp.'insurance required.) 9. Demolition❑ m 4.0 i am a homeowner and will be hiring contractors to conduct all work on my property. 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 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 'nese sub-contractors have employees and have workers'comp.insance.t 13. Roof repairs ur 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.0 Other 152, 1(4),and we have no employees.No workers'camp.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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andJob 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 fy under the pains and penalties of perjury that the information provided ove is true and correct. Signature: ti(/ Date: //) 42 phone#: E ^Vegr0—`039 rr 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#: / TettCommonwealth of Massachusetts et Division of Professional Licensure Board of Building Regulations and Standards Construction-SUp&visor Specialty • CSSL-099486 Epires: 11/01/2019 -- PETER JSMITH ! = P.O.BOX 36 5 " / CUMMAQ ,Tt.�UID MA.Oji \\ • INN Commissioner CA • I ' fuEIaJ02SJapUn 2£930 VW'alnovomna 1S NIVW36 • S £ '�� '` H11WS T H313d '' �rISY: Fa 4�) h .� s yy F�lIWS T H313d Mg/St/so t,. 'Oseos Lolle�lax3 \bo1Weaslbad Rnmpurt9dA1 . 601OVu1NOO 1N31/63A0UdWI 3 BCH uolteln6au asaulsng g sump'iawnsuoa{o oagio rfarmaM'OClj�/akarineozency o :1 • i