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Home My WebLink AboutBld-20-3066 g•YAR g\abl tq g Office Use Only `r�; • Permit# (� T•O y ; Amount 10 - _�3,' ..+�, 6�d' :1 Permit expires 180 days from -. : ; ::...• 6 j' l ,issue date --- -, RECEIVED-" EXPRESS B i ` PERMIT APPLICATION 1 TOWN OF YARMOUTH " I Yarmouth Building Department au i . 1146 Route 28BY _ - T I) South Yarmouth, MA 02664 r�� "``� �� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: it C /:/v3 t, i ;aJi kri p/ 4 s„ ' ill / K ll26 ASSESSOR'S INFORMATION: /� / ClMap: Parcel: > Ud OWNER: w 4/h CPiA7-5 /b0 If,,",, i C , i,6 c-�! s ( • c is q(',5 ?2.3 '\ NAME Mr-SENT ADDRESS TEL. # CONTRACTOR: L J e A'i/ J A/ 1' -!J V+ fc - /If", :, a 0 7 c . .-) ,(,/39, 'J Ai MAILING ADDRESS TEL.# (Residential 0 Commercial Est.Cost of Construction$ 50C1..) I q Home Improvement Contractor Lic.# qL Construction Supervisor Lic.# 2 Z f Workm Compensation Insurance: (check one) ' / 1 q Cl/ IIVI 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:# Replacement doors: # 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: .* „6 414, IOr 90/r '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 my license and for prosec . der M.G.L.Ch.268,Section 1. Applicant's Signature: - ••` Date: �' Owners Signature(or a . • r ent) Date: //r2///q Approved By: Date: ///Z.4/ B,/,ding Official(or gnee EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No . The Commonwealth of Massachusetts =4_ /, Department of Industrial Accidents =ne= 1 Congress Street, Suite 100 0 Ira''`_ Boston, MA 02114-2017 www.mass.gov/dia IMP Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): f IX9� //Z. �.:+ Address: // ) '.' r; -� 1' / / ;; ,- j') City/State/Zip: , :� �;-1,:, ,,---, 1) k c d " yl- Phone #. ,s L't -1l�G' - /3/t‘ 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.Val am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling y capacity.[No workers'comp.insurance required.] 3.Iaam a homeowner doing all work myself. 9. `_'Demolition y [No workers'comp.insurance required.] 10 E 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.El Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.0 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. 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. 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 hereby certify u gr the p'ins and penalties of perjury that the information provided above is true and correct. •Signature: .� ei �� Date: _j '1 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#: DURABLE POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: THAT I, Acilde Cruz Shaw, of Yarmouth, MA do by this instrument hereby make, constitute and appoint Said Cruz, to be my true and lawful attorney-in-fact for me and in my name and stead, to do the following: To sell the real estate located at 160 Higgins Crowell Road, West Yarmouth, Barnstable County, Massachusetts upon such terms as may seem fit to my said attorney-in-fact, and to execute, acknowledge and deliver any and all agreements, and other documents necessary or convenient to accomplish the processing of a short sale transaction, except a Deed. I hereby give my said attorney-in-fact full power and authority to do and perform all and every act and thing whatsoever requisite and necessary to be done in and for me as fully, to all intents and purposes as if I might or could do if personally present, with full power of substitution and revocation, hereby ratifying and confirming all that said attorney, or his lawful substitute shall lawfully do or cause to be done by virtue hereof. I give him the power to sign any legal papers, endorse any checks, or to do any lawful thing on my behalf relevant to the sale of said real property. My said attorney-in-fact may appoint and revoke the appointment of one or more substitutes under him. THIS POWER OF ATTORNEY SHALL NOT TERMINATE UPON MY DISABILITY OR INCAPACITY. IN WITNESS WHEREOF, I have hereunto set my hand and seal this date, February /3 , 2019, at / wpm , Massachusetts. County of: &I.IP�I'�S cilde Cruz Shaw Commonwealth of Massachusetts On this /3 day of February, 2019, before me, the undersigned notary public, personally appeared Acilde Cruz Shaw roved to me through satisfactory evidence of identification, which was daver=e-lieertse, to be the person whose name is on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purpose. Notary Public 41'i/24o_ RI , 7'zvs4" .��9�.� lb�'t�" SKI K'OL•L}:42i ��U'Ravi wGai, ,ibi3488Ct1UBBt�1 My Commission Expires 09/0312 02 r MyComExpire. ,:,,,Atanixt 5,202s c. Commonwealth of Massachusetts IIr� Division of Professional Licensure I Board of Building Regulations and Standards Con str.i,ttAii ittlpFrvisor �ires: 1012212021 CS 111941 _ 4 4 t ERIC D DEMARTIN \ "1 / 167 MANNING=fTREET,G: \ •� HUDSON MA 01748 `` Commissioner C%1 �G z� tCammontaeal� oC' tiauacfrmterla €, Office of Consumer Affairs i Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual EXRIral Ian 190196 01/02/2020 ERIC DEMARTIN i •1 ERIC D.DEMARTIN ��"`�0 167 MANNING ST , HUDSON,MA 01749 Undersecretary i. 0 •