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Home My WebLink AboutBld-20-001412 Ottice Use Only . og'Y'yR ... `4' Permit# SD- O - - y: Amount �n n :..-' Permit expires 180 days from `' s w- '7 i 14 1 - issue date RECEIVED EXPRESS BUILDING PERMIT APPLICA ION TOWN OF YARMOUTH SEP 12 2919 Yarmouth Building Department R- 1146 Route 28 R`'I T:3y South Yarmouth, MA 02664 - (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I M A.C.K L''r-!J Z./ "Vjo, —�•/j4R-NS e U rm — ASSESSOR'S INFORMATION: Map: Parcel: OWNER: liPtiV LZ-Aitb 12—�-.I LL 9 /S.c �' a. ,5•/4 lZtvi o vrW4— AME y PRESENT ADD SS TEL # 33 , .ZZZ• T 2"44 CONTRACTOR: S- 66 u#1. NAME (LING ADDRESS L.#C6 p 3(.7 g 740 tesidential 0 Commercial Est.Cost of Construction$ I PSd st Home Improvement Contractor Lic.# 1 8O (Ci 4 Construction Supervisor Lic.# C_S -Q S Q tl a Workman's Compensation Insurance: (check one) ❑ I am the homeowner Wr 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 Replo=winw A_____ Replacement doors: # f c6 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: VA.I .}40U1'' 4.. ' t )N. STekc 1-'L - Location of Facility I declare under penalties of u t�nents 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 d o tion of Iii for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signatu . Date: cal { - V Z- - 1-O \5 it4Owners Signature(or attachment) /+ ��r(,Lt ]�V'W Date: Approved By: ✓ Date: "��"i Building Official(or designee) EMAIL ADD SS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No . The Commonwealth of Massachusetts Department of Industrial Accidents :ii1l�= = 1 Congress Street, Suite 100 'i��— 5 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 Les ably Name (Business/Organization/Individual): 0 Nk ivc / c M c"-)h\ Address: 156 \,.j,T-ci+\/„r.,. -TQr _ City/State/Zip<S . µ2MdJr/f /4, o?L6g Phone#: 'B -3,7-5 7 t d Are you an employer?Check a appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. lam a sole proprietor or partnership and have no employees working for me in 8• 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑Building addition 4.0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'camp.insurance.* 13.Q Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14. Other&-e/Til)-� 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. tContractors 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 subcontractors 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: 9 1.1p.C.► _,,1.,17i,1-P0 City/State/Zip: .'/�.,2 lw,i nil-Kr),DUO' Attach a copy of the workers' compensation policy declaration page(showing the policy numUr 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 ' -• -J ,airs and pen of perjury that the information provided above is true and correct �! ...`.— a ate: - — ZJ t EP • Phone#: /5-6L� -3‘7- 57x-6 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#: L.. 17{ Commonwealth of Massachusetts = Division of Professional Licensure Board of Building Regulations and Standards Constructbn'Supervisor CS-080901 L pires: 01/25/2020 CHARLES E SIMMONS 156 WITCHWOrOD ROAD: F ; SOUTH YARMOUTH MA 2664 'f ircc l:i•`�` Commissioner l/L — T 6 /mieenept- 72:4'( �I/CIiCCCf1[liPfli Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 180664 12/10/2020 CHARLES SIMMONS CHARLES E.SIMMONS 156 W ITCHW OOD RD SOUTH YARMOUTH,MA 02664 Undersecretan