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Home My WebLink AboutBld-20-002880 /:Cii Y.�R- Office Use Only i O _ !YAt, y i Amount v./,ll •`G MA;r CSC:_,4' '-__ It'oo•ato0 ., 6Lp...a Permit expires 180 days from 1 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH N. }; . - Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 C� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: / / gZGI ili 0 0 c Yctisww (Nl� ASSESSOR'S NFORMATION: Map: Parcel: / 1 , ,Li OWNER: r lc_ TEL. # PRESENT ADDRESS ��i 1 „�Z N •� A- -�5 k _t �� 1/l S TEL.# CONTRALTO MAILING ADDRESS , �� NA1vIE l.� Est.Cost of Construction$ ✓�� ` �� J�Residential ❑Commercial / Home Improvement Contractor Lic.# Z6 �o Q Construction Supervisor Lic.# C..� Li Workman's Compensation Insurance: (check one) ❑ I have Worker's Compensation Insurance I am the homeowner am the sole proprietor Worker's Comp.Policy# Insurance Company Name: WORK TO BE PERFORMED Duration— (Fire Retardant Certificate attached?) Wood Stove Tent Siding: #of Squares Replacement doors: #__ Replacement windows:#__ _� Insulation__ #of Square ( )Remove existing* max.2 layers) Roofing: Pool fencing Old Kings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at cc 64/av4t /--;(...,--g-t a,,..._. Location of Facility false answer(s) .t the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any I will be just causear penaltiesfo deni. perjury •n of m : se and • _• • '•I .•er M.G.L.Ch.268,Section 1. for � Date: :: g ::r attainent) Date Approved By: 1/ �� _ EMAIL ADDRESS: Building Official(or designee) Zoning District: C. No Historical District: 0 Yes ❑ No Flood Plain Zone: : Yes Within 100 ft.of Wetlands: Water Resource Protection District: ❑ Yes -, No 0 Yes 0 No The Commonwealth of Massachusetts 4:2 (I, Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 '4,.INN 5.,,,, 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): ---V4A/••'‘. Lit J Address: 5D RO1 I-�S\ \Jo City/State/Zip:% ( (Mot OZ-(g;3 ( Phone #: 3-6S ,9: 7 - `-t`-e2s-- 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 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling VVE any capacity. [No workers'comp. insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 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.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.; I - 14 er Q10 .�tl (2c,/I5cc.,AstJ- 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. J 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 ertify u di the pain v , :••aides of perjury that the information provided above is true and correct. Signature: i►i '/L j. Date: / /9 Phone#: IFSa& ,D-37-Kt2 s 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#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrotti�rl jttlp4rvisor CS-071544 ires: 05/07/2020 • / ' 1 1. I • JOHN M DAVIS `^ I ; 50 PAUL HUSi4jNAY L,N,;/ BREWSTER MA42631 ' '� , 1OISs O--"- • Commissioner CL f V W(Yrmozyuvea A OitO lido Ja 4a e 6 " Of/les of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR nagiTY Individual • �� 1 08/28/2020 JOHN DAVIS , F(1------ 'f; iz JOHN M.DAVIS r4 - C . 50 HUSH PAUL WA" , BREWSTER,MA 02631 Undersecretary / .