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Home My WebLink AboutBLD-19-3569 i RECEIVED "I n lice Use Clnly oS.Y'�RA. -..._ P-/9-0 � tHgc '+� I DEC 12 ?,Dj(�/U�/�J, . .Amomnt____ ,..„<"# i�.DING UEPAYfM1At ( ` Persil<tpires 180 days(min issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTII Yarmouth Building Department - 1146 Route 28 South Yarmouth.MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: c2_3 a_____a (J s/tii .5 -,---"5-.0U u.1><1Q.anLtl!_a/ "-IA 1 ASSESSOR'S INIOItxtATION/- � � 2-04_S � -AL /z4/7�taP/"OU rt— Parcel: 0 j 3. 2 6 .a.,4 ?/QLrz d953 Sr-C . OWNER: J / _ L ('' NAME -r//)a/ B(?6._5a 77) PRESENT AIN)Rt.SS aoe#r .774_, TELd z./7_6 T/( 00j-- CONTRACTOR:. r/ �tAe/itI._( ope .t2t9 7yQnc ec� / CAnr/.2 /// 4 NAND: Int Nli ADDRESS 1I L.a e L)4 � �� f8/-5-521=/Cif 4 C/IicsiJemial ❑Commercial Ea.Cost of Construction S. / C n dam. ) C/ • �/6 Gra Dome Improvement Contractor Lk.#_12-4, 7-6 s - Construction Supervisor lir.# Qk.[1/ Cc_s` Workman's Compensation Insurance: Ick eck one) . I am the homeowner yf am the sole proprietor I have Worker's('ompensation Insurance Insurance Company Name: _... Worker's Comp.Puaic* 4/0 WORE TO BE i'ERFORMED -yL�`y.,,,,,--...21 ��—Y`,",,� Tent Duration (Fire Retardant Certificate attached?) Wood Stove ;T Siding: #of Squares Replacement windows:# Replacement doors: ft Roofing: #of Squares ( )Remove existing*(max.2 la)ers) Insulation_ Old Kings Highwayfllistorie Dist. ( )Replacing like 31;83-for rllike Pool fencing ',The debris rill he disposed of at:_., G PA ark at% 1..Jk STt____..._.__/_g 1+ b eino .___.._.....-. Location of Fara; I dnlate under penalties ofperjury that the statement herein contained are true and coned to the lint of my knossicdge and belief I understand that ally fake ansti rts) edl he rot cause tax dermal in rev coon I. sense and fur prosecution under M li L.Ch.2ha,Section I a Applicant's Signature: Dae' alb f L Oa a urnSi:matureloraNlulunent i 7 e nate: . l L 2-/?--O / r , Apprdvedris-"-��L/ R• Rate: 12 // /7 Building r feint for signs I'M All.nl III`t(SS' Fear/C/1-2,f°✓)$ klye2 (r{'r/a/� - ( t>/eA _ Tanning District: I li:'tnrical District: " Yes No Flood l'lain/one; ' Yes - No Water Resource Protection District; Within IIX)ft.or Wetlands: Yes . No Yes No The Commonwealth of Massachusetts t��—c= 4:.A/ Department oflndustrialAccidents • ::=1i1 a _ 1 Congress Street,Suite 100 • _`�___ � Boston, MA 02114-2017 2,,=,,,� 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): G1-1 jet S'foPt4trit CM LAJ Address: 26 t fl4sJsr,ELb ST% City/State/Zip: 511A-zea , MA- to 6I. Phone#: `1St -S,5`1? - /6 7 Are you au employer?Cheek 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. I am a sole proprietor or partnership and have no employees working for me in 8. gRemodeling any capacity.[No workers'comp.insurance required] ,-,it 3. I am a homeowner doingall workmyself. 9. LJ Demolition ❑ [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 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These subcontractors 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. 14.0 Other 152,41(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 r 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 ny 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$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 certi u r t e pains and penalties of perjury that the information provided above is true and correct Signature: Date: YLl t 1/10/A phone#: 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#: Office of Consumer Affairs & Business Regulation-Mass.Gov Page 1 of 2 Mass.gov Office of Consumer Affairs and Business Regulation (OCABR) HIC Registration Complaints Registration # 176768 Registrant CHRISTOPHER J. CALLAN Name CHRISTOPHER CALLAN Address 269 MANSFIELD ST City, State Zip SHARON, MA 02067 Expiration Date 09/24/2020 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search Site Policies Contact Us https://services.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=176768 12/12/2018 Details Page 1 of 1 . Licensee Details Demographic Information Full Name: CHRISTOPHER J CALLAN caner Name: License Address Information City: Sharon State: MA Zipcode: 02067 ,3ountry: United States License Information License No: CS-064185 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 10/2/2018 Issue Date: Expiration Date: 10/12/2020 License Status: Active Today's Date:. 12/12/2018 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id=25313... 12/12/2018