HomeMy WebLinkAboutBld-20-002781 O ygR 1 Office Use Only
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!;� � I Permit#
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=� c� ��-�" �( Permit expires 180 days from
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Cost
EXPRESS BUILDING PERMIT APPLICATIONv ; I ;
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 22- dj n Y/(L�4 el... L""Ji, ) 11)i & a H,,,,-;h'
21
ASSESSOR'S INFORMATION:
i I Map: ^Parcel:
OWNER: Li 5a i �oe �,[ry.L d a- 2,G ✓A-;Let((-- bin- t o S At-Cdt
NAME PRESENT ADDRESS TEL. # )
CONTRACTOR: NAME MAI5/ • LING O'I 56 Ad Or. C. W2-4 , n l(l, €253)
MAILING ADDRESS TEL.#
KResidential ❑Commercial Est.Cost of Construction$ 2,2 j
! Ofl' -
Home Improvement Contractor Lic.# )) l / ' Construction Supervisor Lic.# 0S'1 004
Workman's Compensation Insurance:K(check one)
I am the homeowner am the sole proprietor J I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (F're Retardant Certi cate atta hed? Wood Stove
Siding: #of Squares 7-2 Replacement indow . # p acement 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: 5 1 7/ it C o
Location of Facility
I declare under penalties of perjury that th= 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 vocat• of my license and for pro- cution under M.G.L.Ch.268,Section 1.
Applicant's Signa Ii[ d., 4/ -f s :._ ' Date: f 1 ii
Owners Sign ure(or att chment) �� .�, =��/ Date: fi l l
f/ ,Approved By: ►`5���' Date: /I lr
Building Offic.•• • • a EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes E. No Flood Plain Zone: a Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes 0 No 0 Yes E No
I
The Commonwealth of Massachusetts
L
t� r
Department of Industrial Accidents
' 1 Congress Street, Suite 100
Boston, MA 02114-2017
�M..5�•` 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): Lo te h 14_ 51-0).,
Address: 1 u-- -i'lIL4 j )2 ,.j
City/State/Zip: ,A„, 025 3? Phone #: �s 7�—
.Are you an employer?Check the a propriate box: Type of project(required):
I.❑I am a employer with employees(full and/or part-time).* 7. _New construction
2. m a sole proprietor or partnership and have no employees working for me in
an
8. ❑ Remodeling
y capacity. [No workers'comp. insurance required.]
3.Q I am a homeowner doing all work myself. [No workers'comp. insurance required.]I.
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
6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repair /
These sub-contractors have employees and have workers'comp. insurance.Z
r3-1)
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other �)
152, 4 1 ,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. n: 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 un r the pains and penal 'es of perjury that the information provided above is tr e and correct.
Signature: Date: 11
Phone : (__ t D r) 4,- 030
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
Phone#:
Contact Person:
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction„SVOeHAtker 1 & 2 Family
CSFA-057006 > yires: 02/26/2021
4'
•
LOUIS A STERGIS
8 STONEFIELEtpRIVEh .
EAST SANDWCCJ MA 02837 e ;
Commissioner CL
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TY •Individual
EXPitagg
LOUIS A STERN
DB/A THE STE-ciii-3'-1o.
IF, 141
LOUIS A.STERG
8 STONEFIELD OR ✓ i
E SANDWICH,MA 02537/'
Undersecretary
4