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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 39.8-2231 Ext. 1261 y�
CONSTRUCTION ADDRESS: Z-5
/ hnl✓(4(AJJvl-c . )wJ uAA. W CIA,I(W M MA 024109 3
ASSESSOR'S INFORMATION:
�,i
/ Map: Parcel:
OWNER: 1 tri{t 9 fM.U4ikii 1 LOLIC-C 2.-'5 Wr 1,1 ala-C4 Ikiupu e IA). 'Jtwncvlv7( 5oRt) �tol —1163
NAME /I PRESENT ADDRESS� r TEt.. #
CONTRACTOR: P4t4 1a e• Mcth 4q Ng/h) Mud- 440hktt4 MA 0Von I ( O8)Z74-35g3
NAME MAILING ADDRESS v TEIL.# O
,Residential 0 Commercial Est.Cost of Construction S 11 CIO to
Home Improvement Contractor Lie.# 14 2 p 0O Z Construction Supervisor Lic.# CS — I O.3lA 4l—
Workman's Compensation Insurance: (check one)
0 I am the homeowner ikI am the sole proprietor X I have Worker's Compensation Insurance - - Q
Insurance Company Name: A• T. M . Worker's Comp.Policy# V J C IbO 10 b I U O$5201 D
WORK TO BE PERFORMED
Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares (p Replacement windows:#_ '5 Replacement doors: # 2-
Roofing:
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic I
Dist. ( I tA '')Replacing like for like Pool fencing
Ill*The debris will be disposed of at: V t - MI
u _ 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.- . vocation of my license and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signatu •. �` \I "',�-�, .T.• �`� Date: IZ/11 / i g
40
Owners Signa ire(or attar en" ., It y Date: MI/i ,j�
or ii•
Approved By: A 44# ld'ir / Date: /2 ' /t1 '/7
Building yn's•. esr. ee) 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 ofMassachusetts
)tt Department ofIndustrial Accidents
✓ t:,aa
t* 1 Congress Street, Suite 100
Boston, M4 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
TO BE FILED WITH THE PERMITTING AUTHORITY
Avplicant Information Please Print Legibly
•
Name(Business/Organization/Individual):PABLO C.MARTINEZ
Address: 49 SMITH STREET
City/State/Zip:HYANNIS,MA 02601 Phone#:(508)274-3983
Are you an employs?Check the appropriate box: Type of Project(required):
1. 0 lam en employer with employees(Rill andkepaMime)' 7. ❑ New Conauction
2. 123 I am a sole proprietor a partnership and have no employees working for me it any capacity. S. ❑ Remodeling •
(No workers'comp.Insurance required.) 9. 0 Demolition
3. 0 I am a homeowner doing all work myself.(No workers'comp.insurance required.)tlo. ❑ Building Addition
4. ❑ l am a homeowner and will be hiring contractors to conduct all work on my property.I will 1L ❑ Electrical repairs or additions
entre that all contractors either have workers'compensation insurance a an sole proprietors -
with no employees. 12. ❑ Plumbing repairs or additions
5. 0 I am a general contractor and I have hired the aubsonnacton listed on the attached sheet 13. ❑ Roof repairs •
These subcontractors have employees and have worker'cow.insurance.: II. 123 Other:EDAM I WINDOWS.2 nom,
6. 0 We are a corporation and its officers have exercised their right of exemption per MGL a.152, AND6 cnrr res or IDPEI
41(4),end 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.
1Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit
indicating such.
tContrectors 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 fob site
information.
Insurance Company Name:A.I.M.
Policy#or Self-ins.Lie if:VWC10060160852018 Expiration Date:08/30/2019
Job Site Address:25 WINCHESTER AVENUE City/State/Zip:WEST YARMOUTH:MA 02673
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
fore 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
o
er(QQ'�''���p\p\�enalties ofperfury that the information provided above is true and correct.
Sienatute' 01a;NV0 1 VIADate: 19/t t hit
Phone It:(508)2744983
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#:
.177;14. TOWN OF YARMOUTH
.J Building Department
��
ta---to s 1146 Route 28 • South Yarmouth,MA 02664-4492
aF
508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
BEMOT;ITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L.Chapter 140, Section 54 and 780 CMR, Chapter 1,Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at
25 WINCHESTER AVENUE, WEST YARMOUTH, MA 02673.
Work Address
Is to be disposed of at the following location:
TOWN OF YARMOUTH LANDFILL
Said disposal site shall be a licensed solid waste facility as defines by M.G.L.Chapter
111, Section 150A.;'.
7A%2 w - '�V)� I2 /l / // 8
attire of Applicant Date
Permit No.