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Home My WebLink AboutBLD-20-004154 Office Use Onl O� Y I'a(_/J y y . `� 0; • PbtTnd sy O • . H Amount ? �n a £s ' k....u.o ,.. Permit expires 180 days from : Ems. - issue date ill—E IVED EXPRESS BUILDING PERMIT APPLI A C C TIO ^.�...,r.� TOWN OF YARMOUTH "«w l Yarmouth Building Department L tf ��, 1146 Route 28 BUILDING DEPART►v1ENT South Yarmouth, MA 02664 aY. (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: )7 1.f.,. V.c k IQ ( i , t ��Ayi(n4K J' ( ,,``13 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 6'6Rt-'(. I /l?Gie r,, ✓i /,L, C191shL6 7 Lll i ci3UiL.y /tp)- NAME PRESENT ADDRESS TEL. # / ® (0' CONTRACTOR: LAW: S 3 a. t `vtA lezt a.04.- .,vf Lt.•~ .-,� ri_Zt)b'(, NAME / I MAILING ADDRESS TEL.# t 1/4 ry '' 2esidential ❑Commercial Est.Cost of Construction$ ' ., G e J, i " Home Improvement Contractor Lic.# /7. '12. Construction Supervisor Lic.# C.5 --A, i.L'/ Z v Workman's Compensation Insurance:^(check one) 0 I am the homeowner 'AIT 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 r ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 16 4 4 1 t- 4 r/6'4 L ation 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, y lice or prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ""-- u/ Date: / Z/•1/C Owners Signature(or attachment) Date: Approved By: ,_....."_...e.:: Date: -4S- 10 Building Official(or designee) EMAIL ADDRESS: t.4.445134i` J113(.4lGeer.3 e 4 ftkr t�I chk/ Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts 1— /, +. � Department of Industrial Accidents y/ywhip,; 1 Congress Street, Suite 100 M Mill if lA :• - Boston, MA 02114-2017 ' ,'-M MOv,y�1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): f,,,,,its Zt 1 1.4“A,y;,;.-rde (- Address: 6 V fret,Att. p, koc,l. cs'Ltrr3 City/State/Zip: IJ; 4 (./1 % Phone#: s 2'tr`iz Z'13 6 4 / project(required): Are you an employer?Check the appropriate box: Type of :( Q ) I.E 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.] 9. Demolition 3.0 I 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.Q Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6.0 we are a corporation and its officers have exercised their right of exemption per MGL c. 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: '!ram"' Date: I 24' Z(..; Phone#: L i': Zi LA. ( 1, L L 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#: • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu. ft.) R Restricted I&2 Family Dwelling City/Town,State,ZIP M I Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No. and Street Email address City/Town, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes 0 No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I I,as Owner of the subject property,hereby au`i.rize r S(464,1j.K. Li, I., , 1,a y, 4( Iii the/11 `/re4 4 ' 'r4 on my behalf, in all matters relative/�oy authorized by this building per it application. I / Print Owner's Name(Electronic Signature) Date • SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date i NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics, decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost"