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Home My WebLink AboutBld-20-001180 "O�.YRR Office Use Only Permit# Gj3. O 'ly y 'Amount l0 cs- °"°°°7; End Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATIC Nf _..�i ...! , TOWN OF YARMOUTH SEP 3_ �nill n Yarmouth Building Department k 5 P./,n' 1 1146 Route 28 I -1 tei South Yarmouth, MA 02664 1 -----_ -- 1 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: iS CAAtt f h .. lik,.. .. AA 02473 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: M (,(&A\(, 11/4.)Rycr C sr L . 7111 - SlI - 79PS NAME PRESENT ADDRESS TEL. # CONTRACTOR: gocor.ixt.1 NA>enit. 76 V K."A von 1.,i' Li... 77'1 -511- 701 NAME MAILING ADDRESS TEL.# ri$esidential ❑Commercial , Est.Cost of Construction$ 1 / 5-DO .a:. Home Improvement Contractor Lic.# f 1 7 t1 2 Construction Supervisor Lic.# 0/4 - 6T1.J i'3 Workman's Compensation Insurance: (check one) 0 I am the homeowner /1,,I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED 7-a/0iz /-1a X. Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing K *The debris will be disposed of at: 0✓+ S it I"L Co nki.!►4' Location of Facility I declare under penalties of perjury that 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 revocation of mya license and for prosecution under M.G.L.Ch.268,Section 1. Q Applicant's Signature: .✓ Date: l�3//7 Owners Signa e(or a •chment) Date: I/374 Approved By: Date: 9.$./9 Buildin ffici e) EMAIL ADDRESS: Zoning District:_ _ Historical District 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No Me/au Le )Qyer _ _ The Commonwealth of Massachusetts �. , L Department oflndustrialAccidents =n'e= 1 Congress Street, Suite 100 _ E= Boston, MA 02114-2017 .M—_ www.mass.aov/dia Sv' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): St1 M ti, M Address: 7 G .a 0.1+ - L City/State/Zip: f-4fs ,MA e 2661 Phone #: ?0 - -z9. " Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction I am a sole proprietor or partnership and have no employees for me in � working 8. � Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. gi Demolition ❑ y [No workers'comp. insurance required.]' 10 El 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. 12.7 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.= 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. f Other �jI p/or / , 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. r 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: kJ/5, Policy#or Self-ins.Lic.#: 'J /4 Expiration Date: i() Job Site Address: ' CC44-U e• City/State/Zip: lam• rttr el 0411n 02673 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 under the pains and penalties of perjury that the information provided aboveq / is true and correct. Signature: Date: 7/J f 1 g 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#: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 M s Boston, husetts 02118 Home Improveiile?i ` itractor Registration �� r Type: Individual . Registration: 147624 SAM NAOOM % Expiration: 07/24/2021 76 VANDERMINT LN. HYAMMIS,MA 02601 Via`, SCA 1 0 20M-05/17 Update Address and Return Card. L Fi e/..Rokstcriicaselal ss Office of Consumer Affairs&Business Regulation HOME IMPROV,4MENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Reaisfriaan.:._: Expiration Office of Consumer Affairs and Business Regulation 07/24/2021 1000 Washington Street -Suite 710 SAM NAOOM , ,,i - Boston,MA 02118 ,W `W =' W SAMUEL F NAOOM 76 VANDERMINT LN: :' � ,,�,...t,a.i',a,Gfs i" --q\��, HYANNIS,MA 02601 Undersecretary of valid without signature Commonwealth of Massachusetts 11 ( Division of Professional Licensure -I- Board of Building Regulations and Standards Constr tcti�iri'Supervisor CS-096833 x" Aires: 11/10/2020 a SAMUEL F NAOOM z t% I 76 VANDERM1NT LN HYANNIS MA 02601 t Commissioner c,"" z7 ............° � � /�\ I/ O: \ /0 . / /77 ' / / ! >z / l f « > . / y ,mo ! < ` /