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Home My WebLink AboutBld-20-2737 of YR il ••r • $' $ s s,,• O; ;Permit# i �Ot, .�H 'Amount µ ATTA M` j , ••"•9d'. iPermit expires 180 days from ;issue date EXPRESS BUILDING PERMIT APPLICATI( ,_v % ' TOWN OF YARMOUTH Yarmouth Building Department ° .) ;i;, 1146 Route 28 \.l!' `u' South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /'d Run Rod M'. 5, //Gfiy10 SA ASSESSOR'S INFORMATION: /� l/ Map: /� /� /J Parcel: 1i OWNER: k€ M q (j,(✓YM 7$ /�',i /'�S Wif. Yee Yitgot ill 6/7—�93— S`��70 NA/GM& Jwd r� 1PRESENT ADDRESS� TEL. # CONTRACTOR: FOQar4 /OSge&chucd mod. Lederdir 4 OZ632 �e 27 '- '6'NA / / MAILING ADDRESS TEL.# 2esidential ❑Commercial Est.Cost of Construction$ // Oo O- oo Home Improvement Contractor Lic.# / 0?/3' Construction Supervisor Lic.# CS— O6396// Workman's Compensation Insurance: check one) ❑ I am the homeowner Rn am the sole proprietor C 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 6 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: /Q GJ/1 Ls1tic• /I Location of Facility I declare under penalties of perjury that the stajaments 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 pca n of y license and for prose tion under M.G.L.Ch.268,Section 1. • Applicant's Sig azure: LzG . Date: ////�//9 Owners Sign. re(or .ttachment)"• J (.CA/1 et'�'0_.) Date: // 7 l Approved By: Date:47 / i�i /� Building EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes D. 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 r 1 Congress Street, Suite 100 '\ t Boston, MA 02114-2017 ^4,,�5.•`' _ www.mass.gov/dia \Y orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / Please Print Legibly Name (Business/Organization/Individual): i ;LI'ArCI c g4:i�Tcf Address: /Dr eee iWsdi L7 City/State/Zip: ''A i'1U/lap 2612 Phone #: Are you an employer?Check the appropriate box: Type of project(required): LEI 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. 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.❑Plumbing repairs or additions 5.❑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 S j C ng 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. 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 ains and penalties of perjury that the information provided above is true and correct. Signature: 414ta 374— Date: /1/ 721/9 Phone#: 27Y— 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. EIectrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Su rvisor CS-063941 Expires: 11/11,2020 RICHARD P FOGARTY 4 106 BEECHWO9D RD CENTERV ILLS MA 02632' Commissioner of-- Office of Consumer Affairs&Business Regulation e9 HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. It found return to: aficliattidifin Expiration Office of Consumer Affairs and Business Regulation 130373 02127f2020 One Ashburton Place-Suite 1301 RICHARD FOGARTY Boston,MA 02108 /A RiCHARD P.FOGARTY 105 BEECHWOOD RD Not valid W� tCtiQft> 11!°I3 CENTERVILLE,MA 02632 Undersecretary