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Home My WebLink AboutBLD-20-001324 Mike e Use On y r Pamir/ Aft 5D...._- gGl)--.w-1321 rends s a ISO days tom ism deft r i.Z. ECEIVEDi EXPRESS BUILDING PERMIT APPLICATION _... i TOWN OF YARMOUTH Yarmouth Building Department E ' 1�:� 1019 F 1146 Route 28 ,,,,, ctri i South Yarmouth,MA 02664r it (508)398--2231 Ext. 1261 co1VSIRUCTtorlAMISS& _ .` ►"+?'�" 1° t t_z }Z_ :,.=/► _ - L - ASSESSOR'S INFORMATION Parcel: ONYNER:�c,14►,, — .)-viD g..cc _____"1:rizA a Li V A:dr--_ —. 14-8 (1 - 34,3 z- Hy44Y PRESENT C Ct_t4" kk,) tEL I CONLRAC I Dtt.Cr-! ILLA-S -i+A 1di z'iik c t c . IA/I I-c.4lrt./ohn `0 AL') . —3 6,7-c J4.o NAME MAILING ADORESS5,)/.j d utrist---XE-s Errteridential 0 Commercial Est.Coat of'Construction$ 1 "Lao Home Improvement Ca raetsr lie.# 1 $C!►CO(, 4 _Comarae ion Soper riser tic.II CS — O R c(0 k Worl®an's Compensation in aeaoc (clad:one) 0 I am the hammier Ooraamn the sole proprietor 0 I have Wddoa°s Compensation Imam bananas Company Noma Worker's Comp.Policy#,_ WORK TO BE PERFORMED Teat Dandies (like hrdo t Certificate attached?) Ward Slave 5i.t0Nita jFivrett; Sides: #ofSquares Rspinomraat whadowsc# Replace---- doom f Rooting: #of Squares ( )Ream (sum 2 Myers) h oiadae Old Kings Hi bwayAllatorie Dist. ( )Replacing like for Ea Pool feadag *The debris salt be disposed of at ',/' I .Pic. T ik-`' - qS,t �__ Lontliaa I&dare under polities ofpc: --utaaaeet-hank cerYied are tree sad cone to the best of my knowdge le cad bell I andaae-'that day Hire ooswegs) will be just awe for desid Orel; se pso_ecdioe radar M.4L(i.26t.Seaton 1. Applicant's Similar a.____c __-- -_ ..ice' ^ / Dam _3 "Z.1D c1 .1..,__ ilinki W. Approved By: i _ /. /v _` ` Zeros District Ifistorical District: Yes a No Flood Plain Zae: Yes No Water Rooms Protection District Within 100 ft.of Wedaod: Yes No Yes No The Commonwealth of Massachusetts '4= _ Department of Industrial Accidents • :ml= 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name(Business/Organization/Individual): (\ e<c S t M to!'"14 S Address: 1 S%, V)t--fcm wee City/State/Zip .)rt.tvia vervi t . Phone#: 56 8 - 3 C.Q`7 — 5 7 —C Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(Rill and/or part-time).* 7. ❑New construction 2.gram a sole proprietor or partnership and have no employees working for me in 8. Ei Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required]t 9. Demolition 10 ❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole MO Electrical repairs or additions proprietors wittn no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13.Q Roof repairs 6.0We are a corporation and its officers have exercised their right14. Other S L 1'Qfb -- I asr.et_ 152, a and we have noof exemption per MGL c. 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 fob site information. Insurance Company Name: ` Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: t 7 CA PT . t 1\me.re ff SLc / "o City/State/Zip:.S. l �1-12 hI 4 t/T'1F Attach a copy of the workers' compensation policy declaration page(showing the policy num r 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 1 do hereby certi u f perjury that the information provided above is true and correct Signature: Date: 8 -3e - 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#: • -L'imieLY/LL'PCI7/:,1L7/4-i-ieZfYleLdPff/i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reaistr�tlm EgMughin 180664 12/10/2020 CHARLES SIMMONS CHARLES E.SIMMONS' 156 WITCHWOOD RD �'e SOUTH YARMOUTH,MA 02664 Undersecretan Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • Constr{IEtibn'Supervisor CS-080901 4pires: 01/25/2020 CHARLES E SIMMONS• 156WITCHWOrrDROAD./ x ,r SOUTH YARMOUTH MA-O266 k' i • } I/�� Commissioner CA"