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Home My WebLink AboutBld-20-001033 - II�// rr\\ 'l @W av-(0 33 Office Use Only 01.Y4R '7' Permit# S�4'. j-r. 't O O .-, r- y Amount V`� • .d•' Permit expires 180 days from EXPRESS BUILDING PERMIT APPLICATIt) °� TOWN OF YARMOUTH DUI111. 6 9 Yarmouth Building Department [ RTMENT 1146 Route 28 South Yarmouth, MA 02664 508) 398-2231 Ext. 12 1 • CONSTRUCTION ADDRESS: �6 C/'/ 1 i 4J 1.�"bl�4 N,� ASSESSOR'S INFORMATION: Map: 61q Parcel: OWNER: '1Il EY, Cka PI dt,CJ4 tli% ir(1ftW<Q '/1 / 1 / C�S ADDRESS TEL. # CONTRACTOR: lI 1 U34 l ie w /0 5 1/itlf �r( —L.3 4/1— NAME 4�- � #MAILING ADD � TEL. Rla esidential 0 Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# ' /J /J( 2 Construction Supervisor Lic.# O Workman's Compensation Insurance:. ck one) ❑ I am the homeowner 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 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing _ -t______) *The debris will be disposed of at: Atw/��I v JL:re 47.--- m, Location of Facility I declare under penalties of perjury t :4 '. ,/ ' in contained are true and wrre best of my knowledge and b lief. I 'derstand that any false answer(s) will be just cause for denial or re • :.j i and for prosecutio G.L.Ch.268,Section 1. Applicant's Signature: Date:" Owners Signature(or attachme Date: Ca. ( — ( Approved By: ` Date: V —1.6-) Building Offic (or designee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: i Yes No Water Resource Protection District: Within 100 ft.of Wetlands: I Yes L No L; Yes 11 No The Commonwealth of Massachusetts `*= r t Department of Industrial Accidents I Congress Street,Suite 100 = fiE= S Boston, MA 02114-2017 www.mass.gov Workers' Compensation Insuranc- Affidavit: : i �d s/Contractors/Electricians/Plumbers. TO BE FILED d H THE P r ' HORITY. Applicant Information Please Print Lef,;ily Name (Business/Organization/Individual): i/W. ��9/l/•i Address: (5---gd / /'' City/State/Zip: At /(� Phone#: Are you an emplo eck the app .priate box: Type of project r I.Q I a employer with employees(full and/or part-time).* 7. 0 Ne onstruction 2. am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. emodeling 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 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. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 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. tContractors 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 er GL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as w as ' 1 penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy this tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th pal %e alties perjury that the information provi' - , _ Si}nature: � Phone#: �j 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.EIectrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: - - ...... ..... 1 (274 C6Ammonwea/d at ile-LuadoJel6 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE Individual Registration Expiration 157390 09/27/2019 ADAM LABONTE D/B/A FULL HOUSE HOME IMPROVEMENT ADAM LABONTE 15 PAYSON PATH WEST YARMOUTH,MA 02673 Undersecretary Commonwealth of Massachusetts 1ff Division of Professional Licensure Board of Building Regulations and Standards ConstrwtMn'StSpervisor CS-082931 4,pires: 03/13/2020 $ ADAM LABONTE `" C 15 PAYSON PkyH W YARMOUTH MA 026T1 Commissioner CA"