The URL can be used to link to this page

Home My WebLink AboutBld-20-002209 f. '' 01•Y*R‘-0...‘ • I Permit# (�,{ 0-1 i Amount ED :` MANTA P ESE,Sri -C , ""°"•'S° cam:: ;Permit expires 180 days from B• ,)_a u -� Di l issue date EXPRESS BUILDING PERMIT APPLICA I .-- --- TOWN OF YARMOUTH ®c T 212019 Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 B ui� l' - � (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: L1' 2 PA-YrilOn D r l/ c s- l Ai2 VYIOI t d f b I`T ASSESSOR'S INFORMATION: Map: / Parcel: OWNER: �'"S''/1 Ate. X I krndbc0( A(/e g.. (927-c)(3 s---2 NAME,�� ((�� /PPRRESSEENT ADDRESS� 1/TEL. # CONTRACTOR: OW f3Q� P o_ t?JA VzC oe.�G(.A`�STL� n/f4- 5o0`2 37• J—t ea9 NAME MAILING ADDRESS TEL.# 00 Residential 0 Commercial Est. Cost of Construction$ • Home Improvement Contractor Lic.# i q (0 t 15 Construction Supervisor Lic.# c,S - og2.5(07 Workman's Compensation Insurance: (check one) 0 I am the homeowner XI am the sole proprietor 0 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. ( X.)Replacing like for like Pool fencing *The debris will be disposed of at: Ilk MO UT1 LA-9 A-5`m___ D(S P J Filo( LIT Cs Location of Facility 1 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 r cation of my icense and for pro cution under M.G.L.Ch.268,Section 1. / / Applicant's Signature: Date: ! 0 '2/ ( I Owners Signature(or attachment) k Date: a c I Approved By: ✓ -�'' Date: () Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes .t- No Flood Plain Zone: a Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes X.No ❑ Yes )§. No " \ The Commonwealth of Massachusetts Department of Industrial Accidents =LA'- I.= 1 Congress Street, Suite 100 d _E`= Boston, MA 02114-2017 ., -",5••`.. www.massov/dia .g Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): .kf) f // c2 te_,p2yl- 66 7 Address: "�> krQtw e ; 5-03 149ra, Pone Roo-0 , Bkic,� ice, ( 4 0 2t03 City/State/Zip: �j��L j—�� i IVY.4- O2 / Phone #: 52 '237. 5 ( 'act Are you an employer?Check the appropriate box: Type of project(required): I.^I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2.gj I am a sole proprietor or partnership and have no employees working for me in 8. i!!1-Remodeling any capacity. [No workers'comp. insurance required.] 3. I am a homeowner all work myself. 9. ❑ Demolition ❑ doing y [No workers'comp. insurance required.] 4.❑I am myProPertY•a homeowner and will be hiring contractors to conduct all work on 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.E Plumbing repairs or additions 5.❑I am a general contractor and Ihae hired the sub-contractors listed on the attached sheet. 1; ❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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: 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 certi under the pains and penalties of perjury that the information provided above is true and correct. Signature: V-141412 /0' igAtRAY71 Date: i O /Al /1 �f Phone#: 509 ' 2 3 7 ' 5( 09 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#: Fewayoeveivea4e.9-",./Azci,...1,eze...‘„teal. Office of Consumer Affairs&Business Regulation f HOME IMPROVEMENT CONTRACTOR • •Individual .E2IBirAgn .6 ---7 07/17/2021 •- KENNETH W. D/B/A KEN BR -- _ -- KENNETH BRO 563 LONG POND BREWSTER,MA 0263t Undersecretary •- . V; Inst.:- Commonwealth of Massachusetts • Division of Professional Licensure Board of Building Regulations and Standards ConstR4titSri ithIpervisor CS-092867 i r es: 02/22/2021 KENNETH tif BROWN "rt '4 .-_-- PO BOX1.34 BREWSTER MA12631 Commissioner