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HomeMy WebLinkAboutBLD-20-001809 • =OBice Use Only og•Y.9,R- : 0 Permit# O Amount_5 ..t* TM(A' ^ c cd' Permit expires 180 days from =. . ;::::. . '� Bc,)-zo -Is-01 issue date EXPRESS BUILDING PERMIT APPLICATION`. �� ' �, TOWN OF YARMOUTH Yarmouth Building Department O C T n 3 2 Q 1 it 1146 Route 28 South Yarmouth, MA 02664 C0 `-(' 508 398-2231 Ext. 1261 � ) C CONSTRUCTION ADDRESS: 6 .2 i y. k A wf s -c< -�• �4'J2 of -t-- k N Pe-, ASSESSOR'S INFORMATION: Map: Parcel: OWNER: INI LIZ. 6 &! &/ cLS l 1 tsl.,r'SZo,S. I Q ;1,4---'NAME PRESENTC ADD S TEL. #)44-11. 7i� / 78i `� to —$�88 CONTRACTOR:01��A�L L el II ti es'.L- i 5 I \4\Tt..)0.4 0c �. Sty ,t VV A v'c1� +(tA-, NAME MAILING ADDRESS L.#rye_ �$7 s�Residential 0 Commercial Est.Cost of Construction$ �j1 Ja 0 c.) Home Improvement Contractor Lic.# 'Z 6 G 6 4 Construction Supervisor Lic.#C S - (-Nike) 1 p 1 Workman's Compensation Insurance: Oita one) Li I am the homeowner WI 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:# k Replacement doors: # G.)I i,►flow —L I th 4-I400b�C Roofing: #of Squares ( )Rem6ve existing*(max.2 layers) ) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: , i ► - I '"'et S.. Location of Facility I declare under penalties of i, 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 ford j,S c . a lice "for prosecution under M.G.L.Ch.268,Section I. �!, ' �� _ Applicant's Sign Date: to — Z- — QC)`C[ Owners Signs . ttachment) ! ,LOCil-Gt) Date: i D /61l/ Cl Approved By: :�,' Z'" , Date: 47--3 'Y 5 Building lane) E ADDRESS:Zoning District: Historical District: Li Yes _ No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: Yes El No D Yes 0 No • • . The Commonwealth of Massachusetts _- �_'r/ Department of Industrial Accidents 1= 1 Congress Street,Suite 100 z" Boston, MA 02114-2017 www.mass.gov/dia •'r.�ryy411. Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Q‘.4 ,v c/c5 —�\�1 t v LA( Address: \ \,/t.-r e orn© l v City/State/Zip:SSA.A..tiNbt tv( .. 01.6 64 Phone#: S0>8 3C Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part time).' 7. El 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 doingall workt 9. ❑Demolition ❑ myself:{No workers'comp.insurance required.] 10 ❑Building addition 4.D 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. Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q Roof repairs These have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their i 14.[Other�l �Pu ght t;EC GL- ofe required.]ption e MGL c. 152,*1(4 and we have no employees.[No workers'comp.insuranceA�/W!U e�D�J *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: AV A t..)i?'"Itt,U TL o_ City/State/Zip:S. 2 N r►..,a 26 6/ Attach a copy of the work 'compensation policy declaration page(showing the policy num&r 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 ,.• a pains and penalties of perjury that the information provided above is true and correct. Signature: Date: l0 — 2 ZoI Phone#: 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. = Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Const`{tCiIr ti rvisor iJ CS-080901 Uyires: 01/25/2020 CHARLES E SIM • 156 WITC D R• ,1 ' • SOUTH YARM6LTH 'Pi tt 0NS33L,� Commissioner CAL Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE•Individual RQai(ratfon. Expiration ` 12/10/2020 CHARLES SIMMb i. Y 5 «z .. CHARLES E.SIMNJlS 156 W ITCH W OOD Rt) SOUTH YARMOUTH,MA 02664 Undersecretar'