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Home My WebLink AboutBld-20-001783 - i .. Office Use Only N 01.1r1144 - Permit#i` w O• _ yam fob p1 ► .:,,i, Amount �� MATTACM CS[ ' = °`a �° Eta'` Permit expires 180 days from :- .; ` , ` 2-^—17 -3 issue date . CQ/ lv _ V F EXPRESS BUILDING PERMIT APPLICATION • TOWN OF YARMOUTH OCT 0 2 20h Yarmouth Building Department 1146 Route 28 C 44 South Yarmouth, MA 02664 n �►/,((5`08) 398-2231 Ext. 1261 (,��/? CONSTRUCTION ADDRESS: f �1I '4'6Ode. Z�1 ® Q IA) , 7 //� ASSESSOR'S INFORMATION: /q' Map: Parcel: i7/Y 4-47e)-5 ' OWNER:Pfirvk &vet g-4-01 yivEc / (/'17m4)L/ G6 4 /)19( d ! Ck NAME PRESENT RESENT ADDRESS TEL. # CONTRACTOR: ? (�-mr g i nWk jdC�z 'iSS112� 1, i Ce)S)- 7 7r ST(15ma NAME . MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ I / l///7+ Home Improvement Contractor Lic.# /07 ) 2 3 Construction Supervisor Lic.# 69 7 5 2 Workman's Compensation Insurance (check one) ❑ I am the homeowner f; I 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: # 1 - Roofing: #of Squares ✓ Remove existing* (max.2 layers) Insulation g� q � ( ) Y ) Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: YJ� 12""[ / V 7 4 f/e.-- J 199 r " _ 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 denial or revocation of my lice d r prosecuti n d .G.L.Ch.268,Section 1. � Applicant's Signature: y/ �` 'L Date: C(/ 9 W/ (J g Owners Signature(or attachment) aj . at�j/ Date: 9/2 7// /� ` J Approved By: Date: 1� -':1%.i CI Building Official(or designee) 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 of Massachusetts e ._W, = Department of Industrial Accidents _'-Ill= 1 Congress Street, Suite 100 a c= �- = Boston, MA 02114-2017 `''- ^� —5.• www.mass.gov/dia IMP Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): ti)p (/ /3 Address: 3)-c j4 City/State/Zip: Al. �y, -Do,3 Phone #:V t 7 7,r5-3 rj Are you an employer?Check the appropriate box: Type of project(required): 1.,�]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.lYl 1 am a sole proprietor or partnership and have no employees working for me in 8. El 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 ❑ 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.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.�!Roof repairs These sub-contractors have employees and have workers'comp.insurance.; ;;��s�n�� 6_❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other y�v/✓ 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. ;Contactors 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 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains nd penalties of.er'u,y/- the information provided above is true and correct. Signature: Ai,e .1 Date: Tigi://7 Phone#: 7 c ccc -73 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Office of Consumer Altai &Business Regulation • agsutrationE:Individualanarom HOME IMPROVEMENT CONTRACTOR TYP, 107 08/04/2020 BRIAN MCCARTHY- D/13/A MCCARTWBUILCIER$ 747- ;11-7 —7'f-- - BRIAN MCCARTHY 32 CARVER RD W.YARMOUTH,MA 02673 ------_— _ Undersecretary commonwealth of Massachusetts Division of Professional Licensure 19 Board of Building Regulations and Standards ConstructioQ,,,StWiiet 1 &2 Family CSFA-047 505 , -11 6cpires:09/11/2021 BRIAN G MCARTHY 1111:'F 5 32 CARVER R.9 . • ; WEST YARMO9TH p, 3 . v commissioner