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HomeMy WebLinkAboutBld-20-001537 =Office Use Only 3. 4 01.y�* I Permit# O -1+ @ y r<Amount cJ i. ' NATr 1:+ s . 4 '• `" i� l 53 Piermit expires 180 days from :.,. 4 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department SE F 1 ; 211 y 1146 Route 28 South Yarmouth, MA 02664 Cl. Ci/„i (508) 398-2231 Ext. 1261 Yr CONSTRUCTION ADDRESS: I r S t Q / $1 . S J/Act & ASSESSOR'S INFORMATION: ,�yam1 �T�!' Map: Parcel: ff OWNER: /1rn'/Ze k. l'IR2/ATl /C.. ,y y Sohrr,� �A/vniou , filM Cry S-6 .aid NAME 1 r PRESEN A)3Dt✓ 04 1 TEL. CONTRACTOR: A� 5 f 5 C ,i2A ci; 2� (5o9 a 3 7 9 5'rz N C,) MAILING DRESS TEL#/esidential 0 Commercial �j Est.Cost of Construction$ (/_GeV re-0 Home Improvement Contractor Lic.# i 53, ' -/. Construction Supervisor Lic.# i () L(10 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor .I have Worker's Compensation Insurance � Insurance Company Name: A-c0-"•-d Worker's Cotnp.Policy# GUCC ,OCR , So tiBS !p. 690)/A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Repl cement windows:# Replacement doors: # Roofing: #of Squares 1 i C i I( Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 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 license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: / Date: Owners Signature(or attachment) //��• / Date: }`/ �!q Approved By: 2�G„ " Date: -1-I S-15 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No 0 Yes 0 No • _ The Commonwealth of Massachusetts ►! -iv_f" Department of Industrial Accidents C. =E,�II 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. Applicant Information Please Print Legibly Name (Business/Organization/Individual): jr0:2Fit"--j Address: 20 4---1,(/— 1, oe 0 City/State/Zip: 5--(/ Phone#: 50Ra-3 7 f$F2 Are you an employer?Cbeck a appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2 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.[No workers'comp.insurance required.]t 9. El Demolition 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 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 1 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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: /4 (/— Policy#or Self-ins.Lic.#: t CCC . SeQ £, I R.5197 Zcv( 'A- Expiration Date: a 60 ( LCILO Job Site Address: ,S( ...I ill c City/State/Zip: 5 C ` Attach a copy of the workers' compensation policy declaration page(showing the policy number d 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 thep 'ns and penalties of perjury that the information provided above is true and correct Signature: Date: © 7- /6 ' ( 9' Phone#: s6) 37'ls' �L 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. f Commonwealth of Massachusetts ti �/ Division of Professional Licensure Board of Building Regulations and Standards Construtti'biii tipprvtsor CS-104107 cpi res:08/25/2021 CARLOS H FIGUE1ROA ( 7 20 CAPTAIN 19OYES:4 + , SOUTH YARM9UTH "64 -'�" R ' . ,4 - Commissioner /I,(,u,,..4-4t/ D -.( / 1 e ;ru zcvr�efrfl/ Office of Consu /2aad e�e7 merAffairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation 153792 E it i n C&F REMODELING 4NC 01/07/2021 II H. UEO 20 CAPTAINCARLOS NOYES FIGIR RpA �\.��p�� S.YARMOUTH,MA 02604 v Undersecretary l