HomeMy WebLinkAboutBld-20-002106 �;'lr Office Use
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
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CONSTRUCTION ADDRESS: do &5A i ll-j'Cr P/, °4i�_ I fl,
ASSESSOR'S INFORMATION:
I , },,� Map: 1Paarc�el:o �/
OWNER✓`III \l S I I CT, (,765 i �fP1 11/4S�tvl�A- S / �'J��J� -�'C�0�
NAKM PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
'Residential ❑Commercial Est.Cost of Construction$I< /a 0 .CV
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workm 's Compensation Insurance: (check one)
I am the homeowner ❑ 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 p? Replacement windows: # Replacement doors: #
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: Art jell v7.3 4 (Jo
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Location bf 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 I.
Applicant's Signature:_____6/ per. r Date:
./
Owners Signature(or attachment0c)-r—ek _ Date: I U ~ 1 Co — 1 I
Approved By: '_.-4
Building Official(or designee) EMAIL ADDRESS: Date. J(J 6 ��y
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
I Department of Industrial Accidents
,t11= 1 Congress Street, Suite 100
•_'t��- Boston, MA 02114-2017
M IMP . www.mass aov/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): ( ..
Address: 30 1 ; P r M o
City/State/Zip: ; l Nu V \'t-( .O b1 ne #: -5 bci-95 o
Are you an employer?Check the appropriate box: Type of project(required):
I.❑I am a employer with employees(full and/or part-time).* 7. E 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.]`
10 ❑ Building addition
4.14 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.t
6.❑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.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
zContractors 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 ertify under the pains and penalties of perjury that the information rroovvided above is true and correct.
Signature:i + 0:4,,r
✓„J.. Date: 10 ' )[n '
Phone#: � - �D9'_
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 CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
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DURABLE POWER OF ATTORNEY
Know all Men by These Presents that I, PHYLLIS M. CLIFFORD, of the
Town of Yarmouth (West), County of Barnstable and Commonwealth of
Massachusetts, do hereby constitute and appoint my Daughter, DONNA M.
CLIFFORD, my true and lawful attorney with the authority to exercise at any time
or times the following powers, authorities and discretions for me and in my
name:
to demand, collect, recover, sue for, receive and give receipt and
due discharge for any money, debts, dividends, interest, or other property of any
sort, real or personal, now or hereafter due or becoming due to me or to which
may now or hereafter become entitled;
to borrow money, and as security therefor to pledge, mortgage, or
hypothecate any securities or other property, real or personal;
to conduct or participate in any lawful business in my name;
to form, incorporate, reorganize, merge, recapitalize, sell,
liquidate, or dissolve any business;
to enter into and/or carry out the provisions of any agreement for
the sale of any business interest or the stock therein upon such terms and
conditions, including the making of such representations, warranties, and
indemnities, as my attorney shall deem proper;
to endorse for transfer all certificates of stock, bonds, or other
securities; to execute, sign, acknowledge, and deliver in my name any deeds,
bills of sale, or other instruments, under seal or not under seal; to represent me
and vote in my name at any and all corporate or other meetings; and to give to
any person or persons general or special proxies, discretionary or not
discretionary, to vote in my name at such meetings;
z g to maintain, repair, improve, invest, manage, insure, ;rent, lease,
sell, encumber, and in any manner deal with any real or person'al property,
tangible or intangible, or any interest therein, in my name and for;my benefit,
d upon such terms and conditions as she shall deem proper;
to bring and prosecute any action, suit or proceeding at law or in
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equity which my said attorney may deem necessary or proper for the
enforcement or protection of any right or interest of mine; to defend or settle any
such action, suit or proceeding at law or in equity which may be brought against
me;
to compromise or adjust any matter;
to apply for a Certificate of Title upon, and endorse and transfer
title to, any automobile truck, pickup van or other motor vehicle, and to represent
in such transfer assignment that the title to said motor vehicle is free and clear of
all liens and encumbrances except those specifically set forth in such transfer
assignment;
to endorse and negotiate for any and all purposes all promissory
notes, bills of exchange, checks, drafts, or other negotiable or non-negotiable
papers payable to me or to my order, including Social Security checks and
other checks drawn on the Treasurer of the United States;
to deposit funds or property with any banking institution, and to
withdraw any part or all of said deposits;
to make and sign checks or drafts upon any deposits in my name
in any banking institution;
• to employ and dismiss agents, attorneys and brokers and to pay
their compensation and charges;
to go to any safe deposit box to which I have access, and to place
in or take from it any property or papers;
to appear for me and represent me before the United States
Treasury Department, the Internal Revenue Service, or any other taxing
authority in connection with any matter involving taxes in which I am a party;
to prepare, sign and file income tax returns; to pay any such
income tax as may be due and to contest and settle in compromise the levy or
assessment of any such tax;
zto execute any claims for refund, protests, applications for
abatement, and consents to and waivers of determination and assessment of
taxes, agreeing to a later determination and assessment of taxes than is
provided by any statute of limitations;
to receive and endorse and collect any checks in settlement of any
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refund of taxes;
to examine and to request and receive copies of any tax returns,
reports, and other information from the United States Treasury Department or
any other taxing authority in connection with any of the foregoing matters;
to contribute to, terminate, withdraw from, or make any elections,
waivers or consents under any qualified or unqualified pension, profit sharing,
deferred compensation, employee stock ownership or other employee benefit
plan or arrangement (including, but not limited to, life and health insurance
plans, disability plans, retirement plans including individual retirement
accounts, annuities plans, and stock option plans); to apply for, seek
reimbursement from or in any other way to handle all medical insurance and
reimbursement plans; and to do all things necessary to carry out the intent
hereof as fully as I might do if I were personally present.
Delegation of Powers: Compensation:
My attorney is authorized to delegate any powers hereunder; to revoke
any such delegation; and to pay herself reasonable compensation for services
rendered hereunder from any property owned by me or to which I am now or
may hereafter become entitled.
Nomination of Conservator and/or Guardian:
I also hereby nominate the person who at the time may be serving as my
attorney hereunder to be the conservator and/or guardian of my estate and/or
the guardian of my person if protective proceedings for my estate or person are
hereafter commenced.
Third-Party Reliance:
Third parties may rely upon the representations of my attorney as to all
matters pertaining to any power granted to my attorney, and no person who may
act in reliance upon the representation of my attorney or the authority granted to
my attorney shall be bound to see to the application of any money;or property
transferred to my attorney or upon my order or incur any liability to me or my
estate as a result of permittingmyattorneyto exercise anyy power. An affidavit
executed by my attorney stating that my attorney does not have, at the time of
t7 doing an act pursuant to this power of attorney, actual knowledge of the
revocation of the termination of this power of attorney is, in the absence of fraud,
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conclusive proof of the non-revocation or the non-termination of the power at
that time.
Indemnification of Attorney:
I hereby bind myself to indemnify my attorney who shall so act against
any and all claims, demands, losses, damages actions and causes of action,
including expenses, costs and reasonable attorney's fees which my attorney
may sustain or incur in connection with the carrying out of the authority granted
in the power of attorney.
Durable Power:
This power of attorney shall not be affected by my disability or incapacity
arising after the execution of this instrument. My death shall not revoke or
terminate this power of attorney if my attorney, without actual knowledge
thereof, acts in good faith hereunder.
IN WITNESS WHEREOF, I hereunto set my hand and seal on the/,4
day of August, 2005.
�.
P.Fl"�LLIS M. CLIFFORD
Barnstable, ss.
k4
On this / day of August, 2004, before me, the undersigned notary
public, personally appeared PHYLLIS M. CLIFFORD, proved to me through
satisfactory evidence of identification, which was personal knowledge, to be the
person whose name is signed on the attached document, and acknowledged to
me that she signed it voluntary for its s ed purpose.
Notary Public
My commission expires: OPA94/
c7
OFFICIAL SEAL
I • RICHARD G. CARVEN
} NOTARY PUBLIC-ASASSACHUSETTS
, M'Comm.Expires Sept 20,2007
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