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Home My WebLink Aboutbld-20-003193 Office Use Only 0 �'� Permit ..P ._...y��e t A Amount r2 xmrrik e4 vtt i' Permit expires 180 daysfrom �` M� 6'4 .._.. s� issue date EXPRESS SS BUILDING PERMIT APPLICAT b TOWN OF YARNIOUTH DEC 0 3 2019 Yarmouth Building Department 1146 Route 28 i T South Yarmouth,MA 02664 By - (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 923 Rt 6A Yarmiuth Port Sunflower Market Place Building 5 b v,,.... ASSESSOR'S INFORMATION: 1 Map: Parcel: 1 OWNER: Chapter Two LLC _ PO Box 206 Yarmouth Port 508 423-9311 NAME PRESENT ADDRESS TEL. # CONTRACTOR: James N Basler Box 366 Yarmouth Port 508 423-9311 NAME _ MAILING MAILING ADDRESS TEL# II Residential ✓Commercial Est.Cost of Construction S $15,000 Home Improvement Contractor Lie.# 181241 Construction Supervisor Lie.# 012929 Workman's Compensation Insurance:)check one) I am the homeowner Y I am the sole proprietor 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: S & J _ Location of Facility I declare uncle onalties n erjury that the statements herein contained are true and correct to the best of my knowledge and belief I understand that any false answers} will he just ea s for ti 1 r ocation o icen for prosecution under M.G.L.Ch.268,Section 1. Date: �i11 ai2n1 Applicant's Si n r __ ,.n -- Owners Signatu (or attachment) — Date: Approved By: Dais `7 Buildin icial designee) EM. DRESS: jbasler@comcast.net Zoning District: Historical District: ...! Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within I00 ft.of Wetlands. Yes No ., Yes No E The Commonwealth of Massachusetts 1 '� L Department of Industrial Accidents rat 1 Congress Street, Suite 100 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): James N Basler Address: Box 366 City/State/Zip: Yarmouth Port MA 02675 Phone#: 508 423-9311 Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with 0 employees(full and/or part-time).* 7. D New construction 2. '1 am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13, 00f repairs These sub-contractors have employees and have workers'comp.insurance.: 14.gOther Siding 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§I(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: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 923 Rt 6A Yarmouth Port MA 02675 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 ve 'fication. I do hereby tify un:e he pains and penalties of perjury that the information provided above is true and correct Signature: ` 6 .1\\\, Date: I✓c4 V 2 0(7 Phone#: 423-9311 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#: T,� Commonwealth of Massachusetts r Division of Professional Licensure Board of Building Regulations and Standards Const\r,ott'tr(tttlprvisor r CS-012929 -> I Wires: 03/08/2020 JAMES N BALER oi,,,,,,,,I,, UG»- • PO BOX 366 % z .+V. YARMOUTH P6R�T MA` 676 � t N Commissioner CL (11--- - - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual • R@aistration Expiration 18124.1 t 03/12/2021 JAMES N.BASR . x • . JAMES N.BASLER 62..cza.e. - 42 VESPER LANE BOX 366 Undersecretary YARMOUTHPORT,MA 02675 NOTICE , , ,: NOTICE TO —_ -�►� TO EMPLOYEES , -_ _ — EMPLOYEES 7 ===== O14f = vc 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: CHUBB NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO. MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6S62UB-9F6561 1-9-1 9) 04-26-19 TO 04-26-20 POLICY NUMBER EFFECTIVE DATES - MARSHALL K LOVELETTE INS 396 MAIN ST WEST YARMOUTH MA 02673 NAME OF INSURANCE AGENT ADDRESS PHONE# op BASLER, JAMES 42 VESPER LANE YARMOUTHPORT MA 02675 "-- EMPLOYER ADDRESS minmon a, immoin EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE �r- 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 005596 W20PIG15 TO BE POSTED BY EMPLOYER