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_ 4«.uco ,;,Permit expires 180 days from
:issue date
EXPRESS BUILDING PERMIT APPLICATIO --- ------ . __�,
TOWN OF YARMOUTH L C E F
Yarmouth Building Department i - !
-- 1146 Route 28 3() 019
South Yarmouth, MA 02664 =
'� '-� 1 (508) 398-2231 Ext. 1261 L1MET
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CO DDRESS: C j(-ci- c.8_ 0.,..e_vvvokicki•
........_
AS O SESR'S INFORMATION: ✓
Map: � r Parcel:
OWNER: 1c 11.`� 54 Cr Z"`N PRESENT ADDRESS TEL. #
CONTRACTOR: t �` b �1 +2✓ (�G��i(� 50 g C(Z_Z-i 3 Z.„.
N G ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction$ 4 0 01.r
Home Improvement Contractor Lic.# 17-3--I L8 Construction Supervisor Lic.# C S s 0(( (I Z.,V
ExP ` `t-2-4-2A z-1 11- i4 -Zs) Z'
Workman's Compensation Insurance: (check one)
❑ I am the homeowner *1(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 Squaresv.
Replacement windows:# Replacement doors: #
Roofmg: #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: T s.v et. d•' (`jl,LGt, 71
Lon 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 revoc 'on of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: tj - 3 O ' lc(
Owners Signature(or attachment) . Date:
Approved By: <'�" ,. Dater
PI
Building 0 ial esignee EMAIL? .ESS:
c
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
-�- The Commonwealth of Massachusetts
_ Department oflndustrialAccidents
_n,11'11= 1 Congress Street, Suite 100
c _�= l- Boston, MA 02114-2017
'•M�- 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): (�.4 Si 4,1, 't' vtcL,, e,,,,,e 1'' L(p C ,
Address: & L{ CTe►i17'''c i(/ 70
City/State/Zip: W N/44 '✓ MAC- Phone #: S_� Z C( U.1 3 L?—
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.❑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.]`
I am a homeowner and will be hiring contractors to conduct all work on my10 Building addition
4.
❑ o 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.:
6 a corporation and its officers have exercised their right of exemption per MGL c. 14Other 5i��l ` (/:—.5
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-
' 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: 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 and the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: - 3 a _ (cl
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. CitylI'own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
•
Cipro, Linda
From: Lewis Bay <lewisbaybuilders@gmail.com>
Sent: Friday,August 30, 2019 9:26 AM
To: Cipro, Linda
Subject: Fwd:95 Baker Road
Attention! This email originates outside of the organization. Do not open attachments or click links unless you
are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure.
Otherwise delete this email.
Sent from my iPhone
Begin forwarded message:
From: Marianne Sforza<lauman@comcast.net>
Date: August 29, 2019 at 8:27:41 PM EDT
To: lewisbaybuilders@gmail.com
Subject: 95 Baker Road
To the Town of Yarmouth:
I give permission for Ed Stafford of Lewis Bay Builders to act as my agent for the work being
done at 95 Baker Road, West Yarmouth.
Marianne Sforza
Lauman@comcast.net
781-775-2347
Sent from my iPhone
i