The URL can be used to link to this page

Home My WebLink AboutBLD-20-003352 01,�,AR Office Use Only Y � C � ., S' C . H IAmount ..,TAG,, 9 y� .' Qks *ft.. 0 c Permit expires 180 days from t1 *girl) j issue date EXPRESS BUILDING fR1VII APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ff CONSTRUCTION ADDRESS: �� f �Y�_ 14k d (elior)-A. —IL ASSESSOR'S INFORMATION: Map: all Parcel: //, OWNER: J f7 .3 0) n 41 17 f v Cb ll ✓N-► L I (3•10,f A✓� i`'�l/ 1� d hP- • NAME PRESENT ADDRESf l TEL. # CONTRACTOR: t'0'U i S / - S 7 ZS 8 , Do ki,i( /d- G ��7> K/UL t5- os) L? '-Oh NAME 1 MAILING ADDRESS TEL.# AResidential 0 Commercial Est. Cost of Construction$ `6 jrrJ00- � Home Improvement Contractor Lic.# 0It& y Construction Supervisor Lic.# C....)57 Workman's Compensation Insurance:A(check one) I am the homeowner I am the sole proprietor 0 I 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 Replacement windows: # s Replacement doors: # 2._, 5/.!7E� Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: .5 QCCeJ Location of Facility I declare under penalties of perjury th t 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 revo tion of my I nse an rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: - Date: f << l„, Owners Signature(or att e _ Date: ice--/ /21 Approved By: -64—/lk Date: / /'FVV j//7 ding Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes = No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 0 No The Commonwealth of Massachusetts , � Department oflndustrialAccidents -gel, 1 Congress Street, Suite 100 +p �__ 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): LytL A_ .r ya Address: / 2� �� ,tJ� 0 ' City/State/Zip: W-b TY444-PA 02-al Phone #: ( t) '1.. 05217 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 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling a capacity. [No workers'comp.insurance required.] 3.❑ I am a homeowner doing all work myself [No workers'comp. insurance required.]t 9. El Demolition 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.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance. 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-contactors 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 hereb and penalties of perjury that the information provided above is t ue and correct. Signature: Date: j/1 t y Phone#: (, 9z) 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 4: Commonwealth of Massachusetts Office of Consumer Affairs&Business Regulation Ur Division of Professional Licensure HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards TYndividual Construction„ iAS Rhor 1 & 2 Family RegistrExpiration 09/19/2021 CSFA-057006 > 4,p res: 02/26/2021 LOUIS A STER l� DB/A THE STE LOUIS A STE8 STONEFIEL>t IV }� � fiGIS �- i/•lb LOUIS A.STERG .6/ EAST SANDWIMA •37 x` r 8 STONEFIELD D < u % GL•4 ' I ��S�,i`��i E SANDWICH,MA 02597' Undersecretary r, .