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HomeMy WebLinkAboutBld-20-2101 4 Office Use Only o • 4 - .�.2/ f 4414 C" O i1 %Amount MAT s �`+3,I,,,�„r�. `- 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 Ext. 1261 CONSTRUCTION ADDRESS: /049 Coo o 44 , ioroQ G� ASSESSOR'S INFORMATION: Map: /� Parcel: !� OWNER: 0 //#!/Ca/' s� %t� �'c'e" /00 Coo /r e /[J�J © O c U )- 7 '/2%" NAME /' 9 PRESENT ADDRESS /// TEL. # CONTRACTOR: j h r• /47:74, fie- /ES �G / "o.�r� r n�' 570F. 3 ANIE MAILING ADDRESS l� TEL.# esidential ❑Commercial Est.Cost of Construction$ 0 siD Home Improvement Contractor Lie.# / ?O # Construction Supervisor Lic.# C c O 9e, Workman's Compensation Insuranceeck one) ..i I am the homeowner 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 fencing *The debris will be disposed of at: �`' o 75 �^ ''S ` $ 1,( '� Location of Facility I declare under penalties of perjury that the statement erein 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 ion of r li se and for pro9ecut�r M.G.L.Ch.268,Section 1. Applicant's Signature: �r�� Date:,/0 -44_—/.7 Owners Signature(or attachment) L � Date: p' 5 / Approved By: fir Date: 10 ^ IS- I et Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: IJ Yes ;_' No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 40') Yes r No L.. Yes No yy{{[� . The Commonwealth of Massachusetts • A Department oflndustrialAccidents �_ '�,= 1, is _arlrai= 1 Congress Street,Suite 100 _iEfcf=i' Boston, MA 02114-2017 ,� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 1 / Please Print Legibly C- - Name (Business/Organization/Individual): / , 'l /'� !? t-- L C4 .. iCS Address: "4 ( o' $ k 41 . City/State/Zip: $ 4,-,.7 .s /�� 6 ophone#: Ste`' I ) 1'/ 5r. Are you an employer?Check the appropriate box: Type of project(required): i.❑I a a employer with employees(full and/or part-time).* 7. E New construction 2. 1 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.] 10 ❑ Building addition 4.❑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.❑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.❑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.#: �j' Expiration Date: �,/ Job Site Address: /e O Co /� t ��C G� (,� cr. �►'�l��_�� City/State/Zip: l��'�"'o D,-G 73 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 un r the ai and penalties of erjury that the information provided above is true and correct. g Signature: Date: /0 '-/3 / / Phone#: j CJ F 3 7 '-B 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#: ;) Ko-/nri-?(-)-/?ftice{„me//11 r cic;Jaafiti.Adiet(4/ Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 180782 CHRISTOPHER WEEKS Expiration: 01/06/2021 D/B/A"WEEKS" ON THE CAPE 26 NORSEMAN DRIVE S. DENNIS, MA 02660 Update Address and Return Card. Ci 20M-05'17 K/Vee/e/e,/,//,/eil/5' /4 -)//441/jP/i/i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 180782 01/06/2021 1000 Washington Street-Suite 710 CHRISTOPHER WEEKS Boston,MA 02118 D/B/A"WEEKS" ON THE CAPE CHRISTOPHER P.WEEKS 26 NORSEMAN DRIVE S.DENNIS,MA 02660 Undersecretary N valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrptettri Itticiervisor CS-085940 s 4DireS: 11.02/2020 0 4 & 7 CHRISTOPHER P 26 NORSEMAII ; SOUTH DERN 41A•0 Commissioner