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Home My WebLink AboutBld-20-000685 .01', �R Office Use Only ,_ , , Y_ o 4 •20bo6 " r;y� ,H /cY oO j Ou l'/ H Amount °tO+wuc° Ord 'Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261` �, U CONSTRUCTION ADDRESS: 9 9 l A-V-�.., A ` `A,R`tri p 0+1i ASSESSOR'S INFORMATION: Map: Parcel: }��.�� OWNER: 13 AI t �'e-'� \ (?f) if/ , %'1( ow ' ?>�/,�,'�' 7Jlt vI 7-ea (® i, ! ` I NAI P SENT ADDRESS V TEL. # CONTRACTOR: 13 glie .Y!1 1)f NAME MAILING ADDRESS TEL.# /Residential 0 CommercialEst.Cost of Construction$ '"// 2/ ` Home Improvement Contractor Lic.# /c -: ?3,- Construction Supervisor Lic.# C5'Fp- 01, c�q ! 1 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Shave Worker's Compensation Insurance Q Insurance Company Name: —( �'d`r-4'L Worker's Comp.Policy# WORK TO BE PERFORMED Tent.Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ( Replacement windows:# / Replacement doors: # 4)Roofing: #of Squares I ( V)Remove existing* (max.2 layers) Insulation 0 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be awned o et: x.. 1. 1-'` r?vim ° t 41 L ' /.r Location of Facility I declare under penalties of perjury that the statements herein contained are true and .rrect to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for deni• evocation of my tic:, prosecution under .G.L.Ch.268,Section 1. Applicant's Signature: A _ ./—� ' . �ia. ._/ Date: Owners gnature O me'1111111nt) i*'� 111W, Date: c)......„A 671( � Approved By: .a.' 0- ) Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: ` R E C E I V E \ Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 1 `(1/S)''`) Water Resource Protection District: Within 100 ft.of Wetlands: i AUf' ,) i'. t11} I 0 Yes 0 No 0 Yes Li No ,f i N CYE�rv..1. T The Commonwealth of Massachusetts /7, Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 s�•''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/0tgafiization/Individual): ifebtiC iD A r Vc .L feeg, ,rG Address: 3 70"` k /fLGt. A City/State/Zip: �� i' t'1 p cif/ j /►1 Phone #: ef/" 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.❑I am a sole proprietor or partnership and have no employees working for me in 8. [Remodeling any capacity. [No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]` 4.❑ myProPertY�I am a homeowner and will be hiring contractors to conduct all work on I will I uilding addition ensure that all contractors either have workers'compensation insurance or are sole 11.C Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.E1 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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. 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: 7171-rQ.-c ! Policy#or Self-ins.Lic.#: ?gkl ` c4' 4_41 L'f't� p F+ .r��F� Ex iration Date: ,�Job Site Address: /t( iQ._' City/State/Zip: Attach a copy of the wo ers' 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 cer ' un r the pains an enalties of perjury that the information provided above is true and correct. Signature: -4 Date: Phone#: ( 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#: cam- N, 1c -- :2 oz-55Y srizeer - haz-k96- -(14c1 tA100-4 Pa'r( 14-4' Ck/j) C P 3 I f' 4.1._ Ar .41 r!� r'� PJAe ?4nt24upeaith o/1.P as r.f Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual Registration: 180935 ROBERT B. DUNPHY Expiration: 02/01/2019 3 Harbour Hill Run South Yarmouth, MA 02664 Update Address and return card. Mark reason for change. ,CA 1 Co 20M-05,11 171 Pro....1....nrnearot n I ARI4 r**rril Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSFA-069294 Construction Supervisor & 2 Family ROBERT B DUNPHY 3 HARBOUR HILL RUN SOUTH YARMOUTti MA 02664 Expiration: Commissioner 09/14/2018 •. NOTICE A NOTICE TO TO EMPLOYEES ifi EMPLOYEES M UP 5 �4sv The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.0. BOX 1450 MIDDLEBORO. MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6HUB-1 K63222-5-18) 09-29-18 TO 09-29-19 POLICY NUMBER EFFECTIVE DATES = 24 NORTH STREET JOHN J LAMB INS AGCY INC HINGHAM MA 02043 NAME OF INSURANCE AGENT ADDRESS PHONE# DUBLIN CONSTRUCTION INC 2 HERSEY STREET ,frii 1 (, 3a SO YARMOUTH MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE mmrd MEDICAL TREATMENT - The above named insurer is required in cases of personal injuries arising out of and in the course of - employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost.of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO RE POSTED RV F,MPI,OYER . • • �/ eo Regulation - 0 4- Office of Consumer Affairs �eeBusiness S�� 1000 Washington Boston, Massachusetts 02118 Home Improvement Registration Type: Individual Registration ROBERT180935�� Expiration.ratio 3 HARBOUR HILL RUN S SOUTHUTHB.DUNPHY YARMOUTH,MA 02664 Update Address and Return Card. SCA 1 v 20M-05/17