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Home My WebLink AboutBld-20-1455 01.YgR _Office Use Only O -Permit# Oul•' .�(yH; Amount 5(, G NATTA t1 s. ,4 j "`°" �°"'End -;Permit expires 180 days from _' zil issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146Route28 s '' n South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ? ,jO= ; ';' 2�, i,. cU�.; CONSTRUCTION ADDRESS: 31 t,)) o o d �� . ASSESSOR'S INFORMATION: Map: Parcel: OWNER jc M ?1c2uPohd 07-7 tOtc} NAME _ P PRESENT ADDRESS TEL. # CONTRACTOR: �� ` [Q�pS f p.O. 00 C{ y- Port -771"3Y3-(v 0 NAME MAILING ADDRESS TEL.# rr Residential ❑Commercial Est.Cost of Construction$ /A%� - Home Improvement Contractor Lic.# /1158es Construction Supervisor Lic.# f 3/0 l Z) Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0I 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 Replacement windows: # Replacement doors: # Roofing: #of Squares ? ye ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (,'Replacing like for like Pool fencing *The debris will be disposed of at: Yc{1M 0 V‘tit., D j INN110 Location of}scility 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 denials vocation of lice e and for proses n under M.G.L.Ch.268,Section 1. A Applicant's Signature: ) Date: 0 Owners Signature(or attachme t) / / - e<V ( Date: 7/ "14017 Approved By: ✓ —L., Date: 5 -1 6 -1 S Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ 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 p/' Wig kW- Department oflndustrialAccidents Mall 1 Congress Street, Suite 100 _!J. Boston, MA 02114-2017 �M;�5.•`'� 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): Pa-E— ,zk.. £S Address: e c i t)o r 3441.1 City/State/Zip: y-Pori' vtAt 0a-fo-7S Phone #: 77q— 357--6, rag 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. ❑New construction 2t 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 all work myself 9. ❑ Demolition ❑ doing 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.Q 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.1 6.E We area 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. ;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 1z der ze pai and penalties of perjury that the information provided above is true and correct. Signature: Date: ?/67,d0/, Phone#: 771i- `lvSral- 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#: {` r �ie`fvm»,emee /tA tla.unek•u a/lion Office of Consumer Affairs&Business Reg Or HOME IMPROTY VEMENTIndividual BALLGIEffliffn 1 FAR 05/14/2020 PATRICK JACOBS DB/A P.JACOBS CUSTOM CARPENTRY AND REMODELING PATRICK JACOBS 28 W HITTER DR. DENNIS,MA 02638 Undersecretary 11/ Commonwealth of Massachusetts Division of Professional Licensure • Board of Building Regulations and Stac:dards Construction Supervisor CS-081040 E*pires:04/04/2020 PATRICK H JACOBS 28 WHITTIER DRIVE DENNIS MA 02688 Commissioner l