The URL can be used to link to this page

Home My WebLink AboutBld-20-001442 rS r : Permit# itir Amount / 00 Permit expires 180 days from 13 CO -4 24) t I ?..J issue date 9 4 : k e, EXPRESS BUILDING PERMIT APPLICATIOt T TOWN OF YARMOUTHI-F i,j01' Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: V 7 '✓�CCG�-� �� 'Mv�`� �� ASSESSOR'S INFORMATION: e Map: (� Parcel: �i h t�� OWNER: &f I (n �Svt bep l? oieetco S(1' . Y4/plikdA 60P l39- ( NAME PRESENT ADDRESS/ �/ TEL. # CONTRACTOR: Sc.\ l a f s f�r� ' ,s,4 44,( „it, .2Q JG- 6CJ 1 Yy - NA E MAILING ADDRESS TEL.# ?Residential 0 Commercial Est.Cost of Construction$ ! '// vU G Home Improvement Contractor Lie.# Fri l b Construction Supervisor Lic.# l(.3S44-71 Workman's Compensation Insurance: (check one) C I am the homeowner r am the sole proprietor 1 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: # /6, Replacement doors: # I Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: r"G 'h / l4sJ Location of Facility I declare under penalties of perjury that the statements herein contained pre 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 rev 'on of my license and secution under M.G.L.Ch.268,Section 1. Applicant's Signature: Q�j'� Date: �j/ Owners Signature( attachment) �J' r a44?� ��14e Date: O!a y d 1 Approved By: 604. Date: / ! 3 Building 0 " ' (o gn EMAIL AD SS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No u Yes No "at`—'` The Commonwealth of Massachusetts = tr1, Department of Industrial Accidents ErZiiiniff. 1 Congress Street, Suite 100 'E=_ y Boston, MA 02114-2017 www.mass oov/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): J4'f de/ 7 Address: /6J lefr 1 C,,r c City/State/Zip: Y�n,c,. P„/ 44/49. d#1624---Phone#: 3-0 3Cd 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. ❑New construction ? am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. 0111 Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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. Plumbing repairs or additions 5.0 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 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *My 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 employee& 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 r the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /r0///7 Phone#: , 4 D - 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:__ Phone#: Commonwealth of Massachusetts , Division of Professional Licensure i' ' Board of Building Regulations and Standards Construction„ u te''1 & 2 Family Espires: 12109/2019 CSFA-105477 la ,' JASON R BERRY .� 105 SISTERS QtRCLE 1„�, - i ` YARMOUTH PORT MA 02675 �� Commissioner Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reaist[ tii�r Exoiraticn t *& -= 03/16/2020 J:\ ON BERRY;. JASON BERRY �..c..('GG'"e--•— 105 SISTERS CIR. ,--2, YARMOUTHPORT,MA 02675 Undersecretary