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Home My WebLink AboutBld-20-002558` r • c USC tny �, H 'Amount " ' Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231, JExt. 1261 CONSTRUCTION ADDRESS: -77 S Vie Av 1 j yke wtojf J MA-'-- 0740 ASSESSOR'S INFORMATION: Map: � Parcel: g� OWNER: `J/ eF677N /41/6JW 71 .e7I-VIEN/ °1 / 7b -34/6-U NAME �y�� //� PRES T ADDRESS L� /TEL. # �J p CONTRACTOR: CI✓/[ 7/1, kV` • TZ 4 D• -5bx. / 77`T - 7zz r / 36 NAME MAILING ADDRESS /1 TEL. �7ST /"`" 0 2,53 Residential ❑Commercial �11ia Est.Cost of Construction$ Home Improvement Contractor Lic.# ` / y 3 Z Construction Supervisor Lic.# Q p I k 7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor Y I have Worker's Compensation Insurance Insurance Company Name: / 11'f—bD exLfQ tos Worker's Comp.Policy# Wee./ C-6 � r _ JSVt'Ira9rri W �'�� ORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove � I'ding:/#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 fencing *The debris will be disposed of at: V/540 •oii T G4 97 Q1J 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 revoc do f my license d for prosecution under M.G.L.Ch.268,Section I. /17Applicant's Signature: Date: ul Owners Signature(or attachment) Date: /I ( Approved By: PPDate: Building ci des' nee) L ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,n„5.� www.mass aov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): LA/1+/i7 0►,.i -50LI)/j,. 0 b/ifJ6*- #- Address: eO- 4 t T _ /)- /D c/4 m/4 02 5 31 City/State/Zip: -0✓e Phone #: 774 — 7ZZ -7 3FZ .Are you an employer?Check the appropriate box: Type of project(required): l.L,am a employer with employees(full and/or part-time).* 7. New construction 2.❑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 doing all work myself. 9. ❑ Demolition ❑ _ y [No workers'comp. insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on m YP property. I will IO ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 .❑ROOF repairs These sub-contractors have employees and have workers'comp. insurance.: Pl6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other ��. , O �es 152,§1(4),and we have no employees. [No workers'comp. insurance required.] Uthir�tp *Any applicant that checks box 41 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: ASSOG/Peri b k( e &S 2iJ sad er 1 . Policy#or Self-ins. Lic. TM: Vv C - SD 0— Se:)2 -ZDLq A Expiration Date: 'o/-ze Job Site Address: 11 City/State/Zip: S- fA-12-44400�tA 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided ab ve i true and correct. Signature: �,?� (/ f Date: Phone;: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: , ' "Division of Professional Licensure ��l' Board of Building Regulations and Standards Constr4$t$tSr1I tSpffrvisor CS-083184 } sires: 04/28/2020 CHARLES A.-WHIT + PO BOX 601 i d1 f • WEST HYANNISJ ORT 026ZT` 1()IS\3:1L)�� Commissioner c L L , , Aa . Y = 9 W p r Y , _ 3 t y.Iv:—.A 3-� i C F ..., •,' V •tvg, IL , a uP'a