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Home My WebLink Aboutbld-20-000357 o i i ce Use Only k .Y �0 SOD `. 3' .y['r C 7 .Y ••• „'' .. Amount 5 ' �, `Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH 1(l( -? 201 Yarmouth Building Department 1146 Route 28 C South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 0 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: C k V 6 v NAME PRESENT ADDRESS TEL. # CONTRACTOR: l(`Y . `e� )G! v U;�C� Ll ri ( 9�G c/a� I�-e NAME J MAILING ADD S TEL.# esidential ❑Commercial Est.Cost of Construction$ t a u Home Improvement Contractor Lic.# !"1 ) < q Construction Supervisor Lie.# C.S d ?OF U) Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietorj1 have Worker's Compensation Insurance Insurance Company Name: It t 3 ej,�,2`J Worker's Comp.Policy# WORK TO BE PERFORMED 0 t K,-] v 3-�o 1 Tent Duration (Fire Retardant Certificate attached?) Wood Stove (0/13/co, o, Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares a (')Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: S/1Pz.Y CU34\ 1)tty k 1/� Loa o I declare under penalties of perjury that the in 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 r rev 'o of my icense r rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: :;(a)/(361 ()/P Owners Signature(or attachmen ) �� Date: a f Approved By: mac- Date: '44-— Building Officiai 1(or desi EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No 0 Yes 0 No 4 .14 The Commonwealth of Massachusetts Department oflndustrialAccidents :le'- = 1 Congress Street,Suite 100 =I T A _, Boston,MA 02114-2017 ' www mass.gov/dia '7.,�t Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Bnsiness/Organizebo 'dual): Address: n U 3k' e CV, r City/State/Zip:(o\ - �1\W Q 6g u5 A Phone#: f? `ic9s .D.1 -- Are you an employer?Clerk the appropriate box: Type of project(required): 11 am a employer with 1 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or parmaship and have no employees working forme in 8. ❑Remodeling any capacity.[No workers'camp.insurance required-] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property- I will10 El Building addition 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 5.12 I am a general moor and I have hired the sub-contractors listed on the attached sheet 13. Roof airs These sub-factors have employees and have writers'comp.insurance.* ❑ repairs 6.0 We are a corporation and as officers have exercised their right of exemption per MGLc. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks boor#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they me 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-crows 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 Insurance Company Name: I �� `I-e'L Policy#or Self-ins.Lic.#: VJ lg\ <i 3 ?3C) \9 Expiration Date: (n))3 1c90,90 Job Site Address:` 7 ()1\1 k9—'/Z; �/,T /7,./ ..),y1,bk City/State/Zip: %Attach a copy of the workers'coin lion h daratipensa po cyon 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 under the pains ,, , , . , o that the information provided is and correct sistuature: Date: 7 d07o1 Qr _......, Phone#: -Y `--0`-6 , n Official use only. Do not write in this area,to be completed by city or town offidal 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#: } r:6 dam ,oneveaa'a ,&:-�.c e/4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 18Tt54• :- 03/06/2021 KENNETH PERRY D/B/A KP REMODEE{t,P. "" KENNETH O.PERRY _°m " ,,a 19 GULIDFORD RD., CENTERVILLE,MA 02632 Undersecretary Commonwealth of Massachusetts - ; Division of Professional Licensure Board of Building Regulations and Standards Constr. Cty�yriySupervisor \ • CS-076820 F,pires: 08/28/2019 j KENNETH 0 PIERRY r • 19GUILDFORFTROAD'h Y, i CENTERVILLE M,i4 0263- •y`.. ..,. /c�.T i`�J r Commissioner ,.L " -.