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Home My WebLink AboutBld-20-000906 Office Use Only • o1'y C u • ! y -_Amount ` MATT lM £$ =�,***.outs End 13 Permit expires 180 days from '' ;!..#,-"' issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department ____ 1146 Route 28 AUG 19 nlg South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 474--- . 'a 0EPAR MENT CONSTRUCTION ADDRESS: /, 'O ,fIId/ii e Ml. ASSESSOR'S INFORMATION: D Map: Parcel: OWNER: 1 1 l .A. !S Cc'CC 4/1 O 136 IA I D V/vim 12_b y tvd 2T Sr-'F 3‘,31_-3 6/ 6 NAn i PRESENT ADDRESS TEL. # CONTRACTOR: I rk /lfC�C�a /-/7 /or feeckil DS 41 6/I 0-0/K f 2 2 T.f74( NAME / MAILING ADDRESS TEL.# gResidential 0 Commercial Est.Cost of Construction$ ,c UUO•00 Home Improvement Contractor Lie.# / o.373 Construction Supervisor Lic.# CS— O ' ??Y/ Workman's Compensation Insurance: (check one) 0 I am the homeowner )4 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 S Replacement windows:# Replacement doors: # Roofs g: #of Squares ( )Remove existing* (max.2 layers) Insulation `V Old Kings Highway/Historic Dist. (LA/Replacing lcin like for like Pool fencing g b Y (L/1 P g b *The debris will be disposed of at /6u)/1 clump 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 revoc tion of my 1', nse and for prosecu'on under M.G.L.Ch.268,Section I. G Applicant's Signature: Date: Cd/�0/Q Owners Signature(or attachment) Pr----e--)41'. / Date: I/1 7 I I /Q Approved By: Date: )) "1 1 sl Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts 1 Department of Industrial Accidents 1 Congress Street, Suite 100 _a 1_ 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): , rd /oyar7`l Address: /0S- KeecAtdOo ( Ad. City/State/Zip: (efate,v,// 4,, 02(32_ Phone #: 55e-27f 7,(7c< Are you an employer?Check the appropriate box: Type of project(required): i.E I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.E 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.] 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.: 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 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. ;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 certz:fy under the ains and penalties of perjury that the information provided above is true and correct. Signature: e//7//y� Date: 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. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constru # rt"St) r'visor CS-063941 Expires: 11/1112020 RICHARD P POGARTI6 105 BEECHWOQD RD mom•' 4 CENTERVILLE MA 02632 Nw,Ci-tt-' Commissioner a" (Tile t!'ohm inn lemeg/W. /4,;(1 Arfae/!. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Real on F,Jcoiration Office of Consumer Affairs and Business Regulation 130373 02/27/2020 One Ashburton Place-Suite 1301 RICHARD FOGARTY Boston,MA 02108 RICHARD P.FOGARTY 105 BEECHWOOD RD [ u e4-er'ii , CENTERVILLE,MA 02032 Undersecretary Not void wish,