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Home My WebLink AboutBld-20-000989 p'rYA4t Office Use Only > 4.` a, f Q` Permit# 1 H Amount Permit expires 180 days from gq issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 i 40 a $f )Iv (508)398-2231 Ext. 1261 T� CONSTRUCTION ADDRESS: 2.5 / • tV,//Pa..) S?lac.=Z'JTLAJI ASSESSOR'S INFORMATION: ��+r Map: 93 Parcel: (O OWNER: 17065 60/ds:+117Z B ,A 2 Aliovr r og-,005 Cc7Ce'4 NAME PRESENT ADDRESS TEL. # CONTRACTOR: 13✓1/JCiA✓C:" k.01 19Z l t. col" -l0(I/s) ZeksreiC., tt Z-7 7e) NAME MAILING ADDRESS TEL.# •. 'esidential Est.Cost of Construction$ , &e — Home Improvement Contractor Lie.# Construction Supervisor Lic.# /p//✓"..� Workman's Compensation Insurance: (check one) ❑ I am the homeowner X14,I 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 ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencin *The debris will be disposed of at: 58— S F-L/Cjer 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 of m license and for pr se tion under M.G.L.Ch.268,Section 1. Applicant's Signature: fi pP ' Date: Owners Signature(or attachment) Date: � c 4 Approved By: ✓� Date: 7 ' t . ) _)9 Building Official(or desi EMAIL ADDRESS: Zoning District: Historical District: [I Yes ❑ No Flood Plain Zone: E. Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes Cl No ❑ Yes El No The Commonwealth of Massachusetts ' _ _,T4 ft Department of Industrial Accidents " ' :iH= 1 Congress Street, Suite 100 Boston, MA 02114-2017 `4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Arnlicant Information Please Print Legibly Name (Business/Organization/Individual): j' 4...Y,(C4,i& Address: &fZ ld i T b/4.1ti City/State/Zip: e7 OZ7)0 Phone#: -7Z %--Z 3/- 7ccO 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 2.0 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 doingall work myself. t 9. ❑Demolition ❑ y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my p roPertY• I will 10 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 5.0 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.: 6.KWe are a corporation and its officers have exercised their right of exemption per MGL c. 14.4�Other i it•N9A,:' l teerse:4- 152,§I(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: 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 under th pains and pen 'es of perjury that the information provided above is true and correct r Signature:77 � / Date: 7 -fS Phone#: 7ZO Z3/-7000 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#: F",,.'.7rt Michael Williams SI.&1i Fwd-Message from'RNP0026730050A3" Dote- July 25,2019 at 1 15 PM Michael Williams sem imp-, y Vortzon 3 ,sung Clow)smarpAom --) (,.., 4., '7 IV,0 .4...t 4....4 -1'''''' 40,* ,,i 6,. •,...".,, v‘..,1, ,:„..s, , '1.-'14.11N 1.1;%te. EXPRF,ikAS BUILDING PERMIT APPLICATION IO%lit, '.)1;" Y,tt:RItt.it,:tu I ri Yaritic lath llulfiring DepariMatat I 144ii liole 2R SOlth Yarmcari),11.4 C.2;64- 450i)396-1.',3:Ext :AI coN571tUr.T.t.ift A.DatiFX-c• ..,. '4 '/ ,‘,t. -,-,-,-,-... 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Z4U.114 entriva;, als., r t::( r 14 C c, et OkA,i‹..4%.Air:4 Pr3fIrrO0.....YeiaCt W'i1.rs; I T C%t,..Or WcIajci I v z i le. 4 Yes 1 , . I Commonwealth of Massachusetts kV; Division of Professional Licensure Board of Building Regulations and Standards Const`4Xtitr14%tlpFrrvisor CS-101155 14. Aires: 08/27/2020 V. MICHAEL A WILLIAM`t C 692 WALNUT J AIN R� i ROCHESTER MA1 027 1'O/sN T_kL1-t\L' Commissioner V2 .