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Home My WebLink AboutBLD-20-002204 ,'- j r . -A 0\ i Permit# -1 J� /Y OtI�. '10%'r . H Amount `O ,�e• MATTA M £SC' ' �`ftwar.°"4E ;Permit expires 180 days from i issue date BLD- 0-c2a 04 RECEIVED EXPRESS BUILDING PERMIT APPLICATI I N - TOWN OF YARMOUTH OCT At 2019 Yarmouth Building Department i 1146 Route 28 8 U I .1, 44 i AN South Yarmouth, MA 02664 (508) 398-2231 Ext.JJ 1261 CONSTRUCTION ADDRESS: 23 S9-mod.pipc^J� K., , VJuyc 4,,,,,,...,,ciA4k. k 4 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: lO LA (CI ikik Ste.PRESENT ADDRESS TEL. O g 2 So 2 ?-7 / NAME CONTRACTOR: L / NAME MAILING ADDRESS TEL # 12'Residential ❑Commercial Est.Cost of Construction$ . 550 c Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman?Compensation Insurance: (check one) VI am the homeowner ❑ I am the sole proprietor D 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 8_ Replacement windows:# 7 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: kit(4.iGU.‹ '^ &-"c i.'''� — ��JJ Location of Facility I declare under penalties of perjury that t 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 revo do of my license and for prosecution under M.G.L.Ch.268,Section 1. ,� Applicant's Signature: Date: I o f 2 lb f Owners Signature(or attachment) � Date: Approved By: I��l"L Date: r� .2(/7 Build' rc' sib EMAIL AD—L Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes No " \ The Commonwealth of Massachusetts r , Department of Industrial Accidents 1 Congress Street, Suite 100 e V f Boston, MA 02114-2017 N. 's www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1C,i S• Address: 2 c cQ,c(4D;rif-t A.c->Z 4 City/State/Zip: 1Oj clwteuli-1 Mel Phone 4: SC) 2 � 22 Are you an employer?Check the appropriate box: Type of project(required): LEI I 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 any capacity. [No workers'comp. insurance required.] 8. Remodeling 3.Vam a homeowner doing aI]work myself 9. ❑ Demolition y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYProPrtY e 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance. 1 •❑Roof repairs 6.11 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 Ail 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. TM: 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 the ' s nd penalties of perjury that the information provided above is true and correct. Signature: Date: 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 4: (-aLfff aepegz eivat.44 Licc4_ ? /1' / Sqi pea-kJ, ttg 04-€2-K e 23 S 2A4dj7 Ipe -84r l v0---34 Ysziti4,,txxit, //764441 Vou to/? ,l, RECEIVED OCT 2 a. 2019 UILDING DEPARTMENT By: