Bld-20-000182 ;Y44_ Office Use Only •
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fo/� 'l,it .] Amount
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--!'......°"4 e�`�,' `Permit expires 180 days from '
4 issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 4/RC h/"p ' d, ut,13-f p e-/ 1
ASSESSOR'S INFORMATION: / \
Map: 3 eJ Parcel: / 7„
CNER: '1RI All d i-e/l /
NAME !T I� i? SI N I ADDRESS TEL. #
CONTRACTOR: ` p / 'yeller Il/� FRUd2 fl 4"t e - 5 6°.AAA Q-
dlig
NAi MAILING ADDRESS TEL.#
Getesidential ❑Commercial Est.Cost of Construction$ /V t v
Home Improvement Contractor Lic.# 1 7 6 73 c
Construction Supervisor Lic.# \ I o? / 7
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Cgz, J ',Yorker's Comp.Policy# G H c/3 6 32 D '" ,
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares f a Replac ent windows:# / Replacement doors: #
Roofing: #of Squares /Z. ( )Remove existing* (max.2 layers) Insulation `
Old Kings Highway/Historic Dist. ( )Replacing like for like ✓ Pool fencing
*The debris will be disposed of at: In—/"f
Location of Facility
I declare under penalties ofrperjury th atements 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 denial orlrev of m license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Ar Date:
ners Signature( r a ment) Date:
Approved By: 4/ r Date: 7 /7
Building Official(or d ' 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 ❑ No
The Commonwealth of Massachusetts
�, — Department of Industrial Accidents
LA�= 1 Congress Street, Suite 100
_'s � Boston, MA 02114-2017
4.7
` 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): .1)111 ti(Kt C �!
Address: 3 A /e f-Jj IL V' X�
City/State/Zip: a. (64), Al i 1 Phone #: ? 7 7L . 3 -
Are you an employer?Check the appropriate box: Type of project(required):
I.,r/ram a employer with employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all work myself. 9. Demolition❑
❑ y [No workers'comp.insurance required.]
10 E Building addition
4.❑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 11.0 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 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑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.
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 my employees. Below is the/policy and job site
information.
Insurance Company Name: 1T\ V ( .J2 j ' I
Policy#or Self-ins.Lic.#: h t/ ! 3` Expiration Date: J(hJh1 /,7?i
Job Site Address: IZeCL I ' a/t ki444414t-L-Jiity/State/Zipp:
Attach a copy of the workers' compensation poly 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 cer ' under the pai enalties of per' ry that the information provided above is true and correct
Signature: Date: /// ;i /7
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#:
NOTICE , , , I NOTICE
TO =�-
TO
EMPLOYEES _ = = — EMPLOYEES
7 =
O1M = Sv
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017
617-727-4900 — http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152,Sections 21,22&30,this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO. MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(6HUB-1K63222-5-18) 09-29-18 TO 09-29-19
POLICY NUMBER EFFECTIVE DATES
- JOHN J LAMB INS AGCY INC 24 NORTH STREET
HINGHAM MA 02043
- NAME OF INSURANCE AGENT ADDRESS PHONE#
DUBLIN CONSTRUCTION INC 2 HERSEY STREET
SO YARMOUTH.
MA 02664
EMPLOYER ADDRESS
- EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
- provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
- connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Individual before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
02/01/2021 1000 Washington Street-Suite 710
ROBERT B.DUNPHY - Bosto ,MA 02118
ROBERT B.DUNPI-tlt J .'B
94-
3 HARBOUR HILL RUN
SOUTH YARMOUTH,MA 02664 undersecretary Not valid without sig ature
}
r
Commonwealth of Massachusetts
10- f Division of Professional Licensure
Board of Building Regulations and Standards
Construction,,St4'e?"0 f` & 2 Family
CSFA-069294 Expires: 09/14/2020
ROBERT B DUNPHY
3 HARBOUR HILL RUN
SOUTH YARMOUTH MA 02664d
•
,.-
Commissioner C