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HomeMy WebLinkAboutBld-20-003200 •O'i'• -w Office Use Only � ,`v• cCE V D �1 ..2 O Q:-. d ae.. f.+. �v .� ._ m-...ter - -.v', Amount -� q rJ:'4. 5 El. 0 4 20 i9 Permit expires 180 days from E.. ,::. issue date - "3-9Al Tivir-7 T EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: c/ 36 0,4 5 77 So I s2 114 0 L(T k I ASSESSOR'S INFORMATION: Map: a ,::;1, Parcel: / / OWNER: '—.1O2P,y /j/ewa/( /d d c ie� Of G©0P e �-!� /Y14 5 to/2-70 NAME PRESENT ADDRESS / . # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ 2, 5?)v Home Improvement Contractor Lic.# Construction Supervisor Lic.# riWo ' Compensation Insu ..ce: check one) am the homeowner ;,-,:r 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 3 Replacement windows:# Replacement doors: # 7 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: y " 14e✓'-14- -- ,00,S.4 i7z_ Location of Facility I declare under penalties of peijury 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/ , ocation my li se prosecution under M.G.L.Ch.268,Section 1. Applicant's Sign:, ,4/ Date: Owners Signs , /tta,,meat Date: Approved By: I Date: /Z- if '/, Buil. EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes Li No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents = 1 Congress Street,Suite 100 ='C 1 '' Boston, MA 02114-2017 www.rnass.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): �.J aSep// S. 49/P,li-227< Address: $7 S 0 cht4/ 5,1 5 (‘ City/State/Zip: Phone#: Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(MI and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling capacity.[No workers'comp.insurance required.] 9. Demolition 3.n am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.0 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 5.0 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.: li.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGI,c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box Si 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 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 ptmichahIe 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 F e and ' o perjury that the information provided above is true and correct Signature- �� Date: /L/�iy Phone . (S-d V) 6/-2 7/_F Official use only. Do not write in this area,to be completed by city or town offuxaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: December 4,2019 To Whom it may concern: My wife and I are planning to make 81 South St. South Yarmouth,MA our permanent residence in the near future. If you have any questions or concerns regarding this information,please contact me via email at jspiewak@charter.net or phone(508)612-7196. Sincerely, "Yi/ Joseph Spiewak