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HomeMy WebLinkAboutBld-20-00965 01'.Yak Office Use Only v ,k: Permit# C.) ' 1' .4....3. BcD ) rn( Amount -,5-' " trz.„9 ETd .-Permit expires 180 days from i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: a O t L ocv ck 1?C* a Dr tv—€ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Mar t\\th Ne,`S OY ©l Lt .i'>\d Ct,-t, —1—1 (4— 5a,t - 1 c NAME PRESENT ADDRESS TEL. #CONTRACTOR: S M Vm ve,\ N a-� -1 ko Y 0.INGLt/r \ l_A\ —11(-4'' Sat ——)a 0�y S- NAME MAILING ADDRESS 940 Rt S,m n TEL.# C Residential 0 Commercial Est.Cost of Construction$ 1) i n(6 n Home Improvement Contractor Lic.# I ""1 -7 6, . (.1 Construction Supervisor Lic.# ©g to 33 Workman's Compensation Insurance: (check one) ❑ I am the homeowner Ah I am the sole proprietor ❑ I have Worker's Compensation Insurance � Insurance Company Name: N v 1 Mt Worker's Comp.Policy# 1 I 6 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ? Replacement windows:# Replacement doors: # Roofing: #of Squares I ( pt)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: I30. —S\k(_ `o/4-thi'.r 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 revocation my license and for rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: "/?1/ '1 xi Owners Signature(or attachment) Date: U l) l/, / Approved By: / Date: e-2/-yr Building Offici r ign EMAIL ADD Zoning District: Historical District: ❑ Yes ❑ 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 Department of Industrial Accidents =ne I Congress Street, Suite 100 •_' - Boston, MA 02114-2017 -M�S.,' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): SMA Nl CO Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2g I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 E 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.Q 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 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ C 14. Other 12006 ' J 1(�O�q 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. J 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: )J/o14 Policy#or Self-ins.Lic.#: Expiration Date: 1/44 Job Site Address: )-01 Lori ans. or, City/State/Zip: �ikfr AAA 0 )66Ef Attach a copy of the workers' compenseion policy declaration page(showing the policy number and expiratio 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 under the pains and enalties of perjury that the information provided above is true and correct. Signature: Date: 6/2- Phone#: 71 *-c) (- 7Q8 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 Phone#:Contact Person: Commonwealth of Massachusetts Division of Professional Licensure f' Board of Building Regulations and Standards ConstRiction'Supervisor CS-096833 spires: 11/10/2020 SAMUEL F NAOOM 76 VANDERM1NT LN HYANNIS MA 02601 i0A� Commissioner AC (- 'omm/7770Tuc'ea/tA C klC irayktjett l' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR la n TYPE: Individual Registration Expiration 1474 07/24/2019 SAM NAOOM SAMUEL F.NAOOIVI y„ 76 VANDERMINT LN. C HYANNIS,MA 02601 Undersecreta