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Home My WebLink AboutBld-20-002953 e� .01 y •Y Office Use Only 4"* Permit# G ►A.�'`' _ Amount ) Permit expires 180 days from -:' b--av 2 c-3 issue date EXPRESS BUILDING PERMIT APPLICATIO t- -, TOWN OF YARMOUTH Yarmouth Building Department N If ' ,/ ,_0' , 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 �3 CONSTRUCTION ADDRESS: / J-17 71 gives J /`{ eti., ASSESSOR'S INFORMATION: Map: sg Parcel: /5k, owNER: LOPS MAC 4 /7 ,S-(/ e s. Ya.r: 56g - -2 7-4-( &5¢ NAME PRESENT ADDRESS1 TEL. # CONTRACTOR:C AIP1-VCat+ /7' S7il l !�)�aa& .j S.Xt.e. 774-2i 2 -o93d5 MAILING ADDRESSTEL.# esidential 0 Commercial Est.Cost of Construction$ C CID?) Home Improvement Contractor Lit.# /0?2c t O Construction Supervisor Lit.# a -O'? f 33 Workman's Compensation Insurance ( k one) L I am the homeowner am the sole proprietor 0 [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 / Replacementpl windows:# Replacement doors: # Roofing: #of Squares /(O ( ✓)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: M -n• i t '*e Location of Facility I declare under penalties of perjury that the statements herein contained are true and cour:et to the best of my knowledge and belief I understand that any false answer(s) will be just cause for denial or ocation of my license and for prosecution under M.G.L.Ch.268,Section I.Applicant's Signature: ( � Y/i : Date: t//qi'e/ /4 Owners Signature(or attachment) -J Date: I(7 1 4/ 9 Approved By: Date: I I S Building Official(or ee) EMAIL ADDRESS: Zoning District: Historical District: " Yes `: No Flood Plain Zone: .; Yes No Water Resource Protection District: Within 100 ft.of Wetlands: " Yes 2 No 11 Yes r- No s • e. The Commonwealth of Massachusetts } =*D1�A/ Department of Industrial Accidents ` iest.y 1 Congress Street,Suite 100 5M�1— 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 /�► Please Print Legibly Name(Business/Organization/Individual): C .Q -y rPI cei /, I!7 C. Address: l 1 97.11 & f. /e-e. City/State/Zip: S .Y4 Vb 0?16e, Phone#: 934— ,U2- eis 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. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling arty capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 10 Building addition 4.0 I am a homeowner and will be hiring co tractors 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 5.0 I am a general corer and I have hired the sub-contractors listed on the attached sheet. 13.1c l Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6. We are aand its officers have exercised their right of14.Q Other 152,§F(4) artd corporationava no � exemption per MGL c. employees.[No workers'camp.insurance required.] *Airy 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 tContractors that check this box must ached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. lithe 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.Lie.#: 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 S 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 certtii;fy under the pains and penalties of perjury that the information provided above is true and correct. Signature: ('" ' '( Date: Mitq/ZOa Phone#: 7 `l '.Z(.?-0932 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: z _ Commonwealth of Massachusetts i Division of Professional Licensure Board of Building Regulations and Standards Constructlbn Supervisor CS-096633 lA,pires: 08/2012020 CHRISTOPHER A V: 17 STILL SR0 i � SOUTH YARM `� }it"� Commissioner .TP yniiiiii�ir»vvif�i rlf l�ii:Y1�r/ir-3rfli Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation HaWilailan .Exl:iration 102060 05/17/2021 C.A.VINCENT,INC, CHRISTOPHER ANCe4T' 17 STILL BROOK RD SOUTH YARMOUTH,MA 02664 Undersecretary