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Home My WebLink AboutBLD-20-002361 O�•Y�kQ'' rt# v F O Z ' �0 O . .. � . 0-37Amount ` A~T C fSE "' 1Permit expires 180 days from ..=-*,;:-:-./ i issue date EXPRESS BUILDING PERMIT APPLICATIL _ 1 F j; TOWN OF YARMOUTH Yarmouth Building Department ill;. >) ,iO1' 1146 Route 28 i t i, -A 'Vl t 4 South Yarmouth, MA 02664 , (508) 398-2231 Ext. 1261 LAC` CONSTRUCTION ADDRESS: ["( Pt 2 GI, 1,kk d o a2 < 5 ASSESSOR'S INFORMATION: Map: Parcel:G OWNER: �!J 1 S L—Uy �� \ 14 #SZ641,466>R NAME PRESENT ADDRESS TEL. # CONTRACTOR: I3 ?'( R U3 T ( Q' S 0+q ,IS aIfs r ti a 4' -1 7( t S a � NAME MAILING ADDRESS TEL.# (7 Residential 0 Commercial Est.Cost of Construction$ I 0 00 , 0 03 Home Improvement Contractor Lic.# 11 FJ 1 Z Construction Supervisor Lic.# CS OG... 1149. Workman's Compensation Insurance: (check one) 0 I am the homeowner V1 am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: N G i^'' 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 AJ° Old Kings Highway/Historic Dist. (64)Replacing like for like Pool fencing *The debris will be disposed of at: y Ake-.G . '14 L.,,,\"41 r 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�e and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:f'ylo 0 ��(///��(// Date: k V (2.— iS S Owners Signa re(or attachment / Date: Approved By: 1 .1 Date: / -,2f"'/7 Building Offi ' (or gn EMAIL ADD Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No csaN'� The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 „•5" www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): !✓1 /�!Z l2 i3�/ Address: Stk ( g S(-f& J)yc& c r P City/State/Zip: S< )/r4e•^'kOv«-1 ti„ � Phone 4: ce E S.3 2_ 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.KI am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp.insurance required.] 8• El Remodeling 3. I am a homeowner doing all 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 mY property. I will 10 El 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.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other Doc)(2 152,§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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ( S-/' Date: 1 CJ 2 I Phone#: CGS `?—1 6 i $ S Z 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#: Vvn n <,4 I . , Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYRE;Individual Beyistt'itlollv Expiration 04/21/2020 MARK RUBY �� `-- ,i,c D/B/A MARK RIJ &R MQDELING 11 MARK P.RUBY i v _ P 18 SHADY REST[ ,, ,"4' SOUTH YARMOUTI4' '`02664 Undersecretary Commonwealth of Massachusetts ��/ Division of Professional Licensure Board of Building Regulations and Standards Constr idtP illIS ypervisor CS-065149 rxpires:08/04/2021 MARK RUBY; 18 SHADY REST DR SOUTH YARMQUTH MA 64 M ♦ ` 4 ' Commissioner ,G..,.c y .4--- • Y