The URL can be used to link to this page

Home My WebLink AboutBLD-20-00321 Cake Use Only 1 Paoli,'— ' ,,,'";it - to- - Amount5D j &U)-w_1321 Fmk expires 1M Ma's from li°,. ECEIVEDi EXPRESS BUILDING PERMIT APPLICATION - 1 TOWN OF YARMOUTH jEP 10 2019 t Yarmouth Building Department i 1146 Route 28 evi.,e, ,_Y iSouth Yarmouth,MA 02664 _ _ (508)398--2231 Ext. 1261 CONSTRUCTION AIlIl i " " - �- ' -),,,Atii___vvnksrA-- ASSESSOR'S INFGRMA110 Mor Parcel: OWNER: .ac 14 14 ' "" ` runoffNAMr A SS •C+aiars ,y Tom,. • coNIRAcita. AjUt C M atk\ 1r,4, Lt lTcP Iot , 12..E . 5 -36,7-A"J.. O NAME MAILING ADDRESS,yo a u4.11--3[.a lifesidential O Cromwell Eat.coat oeCanoe:ddon$ I ZOO Nome haproveasoat Contrweerr Lie.• t $C)Co(c f" Camlrwetioa Supervisor Lie.0 CS - OR CLQ 0 k Worinnan's Compeametian Insonnee: (duck one) 0 I am the homeowner ao in the sole proprietor O I have Wado's Cain Magnate Insurance Company Nemec Wodter's Comp.Policyt!_ WORK TO BE PERFORMED Tent Duration (Fite Retardant Certificate attached?) Weed Sarre #of Sq uares t0)etc. 1 ? Tte 2 wi•dow=a_._._ Repkcesent isoom I Roofing: #of Spnem ( )Bete Onax.3 tayen) Insalm ra Old lCinp Hkeray/Hintorie Da ( )Repladng like for Ike Pool> 'Me debris will be&posed of at ,/` rZ l e..(sr k.fl_i)t c5_ Pe Loesflos ofFseMiy 1 deohre wider pawn dpc.,04 ' ' beak aostseed ate Use aid cannot to tie best day knowleggs and belief, 1 aaimad net say Moe aaewegs) will be just kr drain dartT .nee s praeeafioa maw M O L Ch.26$.Section 1. r Chasers Slsnbre(or stawinsn _ DI Appnoma BY: __ nets 7/t5—'1't ADDRESS: Zoning District Historical District Yeas 3 No Flood Plain Zone: Yes No Water Resource Pretection District Within 100 ft.of Wetiandc Yea No Yes No The Commonwealth of Massachusetts -. 14►__ '/ Department of Industrial Accidents =�►�- a 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. Anolicant Information Please Print Legibly Name (Business/Organization/Individual): C\..s.moo_ tee s ' l t j (j s Address: 5•C, 14/►-fc,1a,\.I Iaa o Z� City/State/Zip5.)//4 K,e it o%Pnth , Phone#: - 3 (.21 — 5 7 Z—c • Are you an employer?Check 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.gram a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 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 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general con actor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13. Roof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL e. 14.( OtherS[.►�� 1VSV . 152,11(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. :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 and Job site information. Insurance Company Name: _ Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: t 17 CAPT. INI1 G1L<<it_Ssw'o City/State/Zip:S. l 4-J214Q ✓rJ4 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 I do hereby c ur enalti f perjuty that the information provided above is true and correct Signature: te: 8 -3es - 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#: / Pi�ri�e�iitt�allC �ai-Jae �Jeff-i Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reaist, r`tfon x ira'on rI 180664 12/10/2020 CHARLES SIMMONS CHARLES E.SIMMONS 156 WITCHWOOD RD �'2 � j — SOUTH YARMOUTH,MA 02664 Undersecretar Commonwealth of Massachusetts 5 Division of Professional Licensure Board of Building Regulations and Standards Construct-ton,Supervisor CS-080901 4pires: 01/25/2020 CHARLES E SIMMONS 156 WITCHWOOD ROAD.,,' SOUTH YARMOUTH MA 02664\ = Commissioner CL