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Home My WebLink AboutBld-20-002459 O�,7rAR �vuiw uSC vuiy ' ..! p Permit# ss 1 AJ fO/1 '`xz*'1' '� i Amount 50 •�M,A,�TTA n,of5[/ j 'a�°"°"`f°oc.PI Permit expires 180 days from j issue date LAJ—wla(1,E- EXPRESS BUILDING PERMIT APPLICATION 1 A'-k. TOWN OF YARMOUTH Yarmouth Building Department # 1146 Route 28 till `) 2019 South Yarmouth, MA 02664 a (508) 398-2231 Ext. 1261 Ce..,_ ._ ._ CONSTRUCTION ADDRESS: 3 Cl,4,( LAC, (,4 ratfr..J1n 671G 7 3 1 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: /t e inn;c /U,cYer 3 Ct.Acr L., w' Y,E,A.u•-11n ,LMQ 02-4.73 - 77(4-52(-Mc NAME PRESENT ADDRESS TEL. # I'• CONTRACTOR: SA006, /�,�Qa . �E' `/,UF2[v1Nf L ,[,.,) A 771i-5;2L-7995 NAME MAILING ADDRESS �� TEL.5 µ#' lit•Residential ❑Commercial � Est.Cost of Construction$ c�Q '"' ^ Home Improvement Contractor Lic.# 19 ( ('2i Construction Supervisor Lic.# 0'16 333 Workman's Compensation Insurance: (check one) ❑ I am the homeowner K"I am the sole proprietor C I have Worker's Compensation Insurance Insurance Company Name: /A Worker's Comp.Policy# N/A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares /t ( X)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Om - 51 T C COn k L. 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: .4/ Date: (0 f 9/'C/ Owners Signature(or attachment) X Date: 1 n hi /i i Approved By: Date: /a^ ,--// Building Official(or ib EMAIL ADD 4)4_ Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes No • The Commonwealth of Massachusetts 11, Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ',N..5.•''y 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): S/kMoCL F. Address: ) ( Va. �r�►.iy L„. City/State/Zip: /-i,7 Arody , AAA o a ,0 Phone #: '?? tf —521-7&q Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. New construction 2.k am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8 ❑ Remodeling 3. I am a homeowner doing all work myself t 9. ❑ Demolition ❑ y [No workers'comp. insurance required.] 4.❑ my I am a homeowner and will be hiring contractors to conduct all work on property. 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. 13.El Roof rep//a��irs , L 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other lac 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: kJ J Policy#or Self-ins. Lic. tt: It)IA Expiration Date: A J/A- Job Site Address: 3 Cyr L.,. City/State/Zip: Lv• Yit ,�A a2g.1 j 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 above is true and correct. Sig-mature: Date: I a),I`11t� Phone44: 7 ) b —5-21 —T99S 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#: Im.'• Commonwealth of Massachusetts Division of Professionql M Board o Licensuref Building Regulations and Standards Consottkiti/Sttpfrvisor • CS-096833 pires: 11/10/2020 • • • SAMUEL F NAOOM 4iht ••'•':•‘' 76 VANDERMINT LA( '1/11 `,/• HYANNIS MA 6'2661 4.--- Commissioner CL 409Z0 VN'SINNVAH fuelenesiePun INIINEGONVA 9L 1itOVNd13flvlVS aLqfti'fi--1,V,‘. 7,41' Lit AL ,INOOVN INNS -( 1•ZOZA7Z/LO4-' uoilLIFIX2 " lenPIA!Pul uonitleiOnBelTissoulditliOsna0 1:118111uv Mincisrluolo3 Vitto°01101110 rgyarvy.gvrtsvr-4/23,vaanAxerzt.,N • •