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Home My WebLink AboutBld-20-004070 - _. _1°nice Use only o R Permit# .O "'I �: 'Amount /a) �. ` ,ATtAC, CU!,sz 1 ,."`"+ro.Aec°"P cam: 1 Permit expires 180 days from .• 6o),71o,ifoz ;issue date � �ll E C E I IEs E EXPRESS BUILDING PERMIT APPLICAT N TOWN OF YARMOUTH lr:i�+` f f Yarmouth Building Department 1146 Route 28 3 :' South Yarmouth, MA 02664 "Y (508) 398-2231 Ext.� 1261 CONSTRUCTION ADDRESS: 73 1 K.�±. t S. la- odrk t IAA-`A- Q;-6' (0 ASSESSOR'S INFORMATION: Map: Parcel: 7 7 • OWNER13I nay' S�-et�r. L LC �)3) ►al✓t 5 - . 568-- (4f- 73J NAME PRESENT ADDRESS TEL. # CONTRACTOR: ?c + ck c 6 b S P b 3 o 3 V if R? 7 J 5 3 USA. NAME MAILING ADDRESS TEL.# ❑Residential Commercial G Est. Cost of Construction$ S� Home Improvement Contractor Lic.# /1/5—Q s- � Construction Supervisor Lic.# t98/ O 'D Workman's Compensation Insurance: check one) I am the homeowner 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: # 2._— 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: 54 dl v v Location of Facility I declare under penalties of perju.• 1 at the tatements 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 r v.. . io of my nse and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: y d/0) 0 —v 49 0 Owners Signature(or attachment -1-"‘--, Date: 3 °� Approved By: � l Date: / / Buildin' i I.�s or designee) Eiv ADDRESS: Zoning District: Historical District: ❑ Yes 2 No Flood Plain Zone: 2 Yes 2 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 1 No • The Commonwealth of Massachusetts i2 Department of Industrial Accidents 1 Congress Street, Suite 100 l, Boston, MA 02114-2017 5�• www.mass oov/dia UN Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): YGt CtIll. Address: e- 0. Boy 39 L-( City/State/Zip: /(il 14.& PAlt 7f Phone #: 77Y-35-3— a 3 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 2,11gi 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. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]' 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 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These 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. Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box;41 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 verificatio I do hereby certi d r th ins and penalties of perjury that the information provided above is true and correct. Signature: Date: //liA0,4-0 Phone4: 77 --3 3 66c<; 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 Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-081040 4pires: 04/04/2020 ,i PATRICK H JACOBS 28 WHITTIER DRIVE DENNIS MA 02638 Commissioner CAI- /fir•'oPI MeliWea/fA 01 fill..;aAii.;eill Office of Consumer Affairs&Business Regulation / HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reaistratton Epiration 165888 05/14/2020 PATRICK JACOBS D/B/A P.JACOBS CUSTOM CARPENTRY AND REMODELING PATRICK JACOBS 6 l--- 28 WHITTER DR. DENNIS,MA 02638 Undersecretary