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Home My WebLink AboutBld-20-001410 Z,- Office Use Only 4" Permit# p - H Amount �V I �'/ . . � r Permit expires 180 days from - - 1�II ZV II��— w]� 4 issue date _...______.__----_____�,._..._.— i E IV E' EXPRESS BUILDING PERMIT APPLICA'IdI - TOWN OF YARMOUTH SEA 1 l 2019 Yarmouth Building Department e 1146 Route 28 F,:I ��' ta4 South Yarmouth, MA 02664 �� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 6 /1gjhe -ye W. Yap'14#,oLSl7 /"1 I O?673 ASSESSOR'S INFORMATION: Map: Parcel:OWNER: g4pdyAk,,,i, 1 eo 302.JAA Vie/11i De/Ai?ke fla 7 7 -3.z9'Sa?C NAME PRESENT ADDRESS 0070.;6 TEL. # CONTRACTOR: CA r/rs ills ,r6 .2e3 tihkii St)(2/inaid4 Ma S'ad'774 /261 NAME MAILING ADDRESS 0 sii - TEL.# Residential 0 Commercial Est Cost of Construction S /oOQ -- Home Improvement Contractor Lic.# //C/ 7/1 Construction Supervisor Lic.# (% 3 47 Workman's Compensation Insurance:�(check one) 0 I am the homeowner /1`�`I am the sole proprietor 0 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: # / Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing l/ 1 'The debris will be disposed of at in ,WM . /f ow) // Location of Facilii' I declare under penalties of perjury that the statement 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 rev 'on on of m license d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:y � ► .. ' "r7/ C2.r�� Date: 9 1 c I, • Owners Signature(or attachment) (� ��`��` Date: 9110 iq Approved By: Z/ Date: `/2.7 Building al(o ign E 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 ' =•� _ � Department of Industrial Accidents c _Tel= 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 LegibIv Name (Business/Organization/Individual): c/1 C Kies 141a tt Address: )d 3 L,//1/00 I City/State/Zip: /004/dbiliyeS Mei O.6Phone#: 5-0 77.6- 1 ? 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 20 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.]I 9. CI Demolition 4. I am a homeowner and will be hiring 10 ❑ Building addition 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? r 6. We are a corporation and its officers have exercised their rightof exemptionMGL c. 14 Other / �� ❑ rPper 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Arty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indiraring they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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:l0 Job Site Address: 3 he rive City/State/Zip:WI YOY1s0 PIA 1 7 U a.d7_3 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 and penalties of perjury that the information provided above is true and correct Simiature: d 1,CV-01-..4�r Date: 9—l Phone#: ,S (1� 7 7 (, /,2. ( 3 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 11 Division of Professional Licensure Board of Builaing Regulations and Standards Constnactibntilpervisor CS-042539 ; ` Expires: 06/10/2020 Li CHARLES J pkAURO , 203 UNION ST% YARMOUTH PORT MA 02676 ` Commissioner V'r"' . • , rirrtvttoP.ecfa ff'✓kmiitcc.4eJetfd i fflae ot C•••`;;s8ca;r,tnai:s''.Sus€Hess Regulation HOME'IMPROVE ENT CONTR;;CTCI~ TYPE Individual - _. 10:18/2019 CH,L;R ES J T I I CHARLES.J.;�laC,t,RO �R CCU•-4'•---- 203 UNION S '� Ar.a0UTHFORT,MA 02675 Undersecr 4 ;