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Home My WebLink AboutBld-20-003156 .O ;YRR l(nice Use only 7 Permit# I O . .. • 'Amount .5(.) N '`°"°"•"° c d$ I Permit expires 180 days from issue date ea-0)0 /S-J61 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department ; .64 1146 Route 28 South Yarmouth, MA 02664 ( -I. r p (508) 398-2231 Ext. 1261 I CONSTRUCTION ADDRESS: Yo 2 5 T I ..) Clef lAt-,4•1 e__ ASSESSOR'S NFORMATION: `` 11 Map: Parcel: AA OWNER: 7 D{1 �0 sco N NAME /�� / h �T PRESENT ADDRESS / �1TEL. # CONTRACTOR: S G i/h ct.j. 4.6. (3 -F 6 5A pA kov.t. 50 6-- 353' 3 NAME MAILING ADDRESS 0(STD I TEL.# 46'Residential ❑Commercial Est.Cost of Construction$ —1 FCCAv •(5° Home Improvement Contractor Lic.# It,1 3() Construction Supervisor Lic.# 041....5C7 Workman's Compensation Insurance: (check one) ❑ I am the homeownerm 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: 'r` 1 13�`eit3b 12.-e, • Location of Facility I declare under penalties of per. - . .•a 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 den.- .r revocatio -nse and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sign. .r:4011.' / Date: t)4.Q. • a �i f Owners Sig,ature(or attac)ment)4J,I\. ._ _ /1't� Z` Date: Approved By: " �h► ``�•=/ Date: /Z ' Z .� Building•fficiM°r d- ee EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: E Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No .. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 . Boston, MA 02114-2017 °�M`,�•`� www.mass.gov/dig \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): C 1 fV‘CO Co s , �.Q41,c_ Address: P. 0 . 6a v , (0/ City/State/Zip: SA4AIVI6 Phone t: 5Z) 33— t533 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 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp. insurance required.] 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ 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.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs Th se 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. 14.0 Other �\r+l. uj,i_ 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi he pains and penalties of perjury that the information provided above is true and correct. Signature: � -2 Date: bee....A Z Zd 1 1 Phone#: %�7j 1 1 S 7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts kVDivision of Professional Licensure i l Board of Building Regulations and Standards Constrocti�rl I$iiPFrvisor (1--- CS-042957 �ires: 09/20i2020 13 J SCOTT CIMENO fir" /' "" ` i PO BOX 564 -, `�V / �" ` SAGAMORE MAti02561 ' ♦� v Commissioner Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. 14(sso Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl