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HomeMy WebLinkAboutBld-20-002341 o' •sr4 Office Use Only 0 Permit# O ,! y: Amount /co- M7 M -, !"""°'" Permit expires 180 days from i)— 34 l issue date EXPRESS BUILDING PERMIT APPLICATI _` .m �_ ._ TOWN OF YARMOUTH Yarmouth Building Department OCT 2 Es 2019 1146 Route 28 4 _ South Yarmouth, MA 02664 B U I L D RTM E N T Gy (508)398-2231 Ext. 1261 ___-- CONSTRUCTION ADDRESS: o2—7 7 co v 1 1/\ ke(`C_ '• / S. '/a f YK,0 ASSESSOR'S INFORMATION: Map: Parcel: OWNER:9 r1 56tZvi 5h8rr Pf 1 , I L C NAME PRESENT ADDRESS TEL. tt CONTRACTOR: Pot- . L_-�a.co c P.©. (3O c 7yy Y-Port 77Y 5' ST3— ' �7L NAME MAILING ADDRESS TEL.# 0Residential Commercial Est.Cost of Construction S Z 5i t Home Improvement Contractor Lic.# /4 5 56 Construction Supervisor Lic.# L)g /0 -( D Workman's Compensation Insurance ( eck one) I. I am the homeowner am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# /0/ 0.-4/S /O a WORK TO BE PERFORMED /03 Tent Duration (Fire Retardant Certificate attached?) Wood Stove lOy /0 5— Sidin : #of S uares Re lacement windows:# l /O U g q p Replacement doors: # / 8 Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Z0( 2-0Z Old Kings Highway/Historic Dist. Replacing like for like Pool fencing 20 3 zos, S *The debris will be disposed of at ?A O Location of Facility 2-1 Z I declare under penalties of perjury t the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) Zl y will be just cause for denial or ,.'o of icense and for prosecution under M.G.L.Ch.268,Section 1 / Z Applicant's Signature: Date: /0 y1 rJ/9 zc Owners Signature(or attachmen �' ✓v� Date: 1 6 I��y //' Zc j , lI D Approved By: 9 /((/ Date: �� 1 2 5" 7/ Buil ' (o designee) EMAIL RESS: Zoning District: Historical District: 7 Yes No Flood Plain Zone: Yes C_ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes L No Yes No i' ':13e'Gm m,,weal/A ne•ff aut rAttJe/.c l Office of Consumer Affairs do Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual BEttlitill0 Expiration 165888 05/14/2020 IF PATRICK JACOBS D/B/A P.JACOBS CUSTOM CARPENTRY AND REMODELING PATRICK JACOBS �kNL ` 28 WHITTER DR. DENNIS,MA 02638 Undersecretary it Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-081040 Expires: 04/04/2020 iii PATRICK H JACOBS 28 WHITTIER DRIVE , DENNIS MA 02638 i l: Commissioner The Commonwealth of Massachusetts e: Department of Industrial Accidents _ iel= 1 Congress Street,Suite 100 • Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aaalicant Information Please Print Legibly Name (Business/Organization/Individual): PA,�'1 _L c0 bS Address: die -e. (7 . (So X 3`(9 City/State/Zip: V, For'k— , VI nit,7s Phone#: 77g1- 3S'3 - 6 v��- Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.®I am a sole proprietor or partnership and have no employees working for me in 8. E,Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑Demolition ❑ ys [No workers'comp.insurance required.) 4.0 my property. I am a homeowner and will be hiring contractors to conduct all work onI will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their righ exempt t of exem per MGL c. 14.0 Other 152,§I(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. 1 ant an employer that is providing workers'compensation insurance for my employee& 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 nder the pains and penalties of perjury that the information provided above is true and correct Signature: Date: /4fj�//ao/9 Phone#: 7 74/ —G�5 --- Official use only. Do not write in this area,to be completed by city or town offuzaL 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#: