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HomeMy WebLinkAboutBld-20-000821 -- Office Use Only s ty! CC.' Fe)--4.,1 + O '+,.�*l .` H Amount !°" cs°E�x Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLIC , P i wE V E D TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 AUG 13 2019 South Yarmouth, MA 02664 IL I EPARTMdr (508) 398-2231 Ext. 1261 By: ENT CONSTRUCTION ADDRESS: r � �c--e-,-)dc,,1( ,„N `2J y i . l I ASSESSOR'S INFORMATION: Map: / 5. Parcel: 6 , OWNER: C 1 '2 7 sk A s n'ic.)lef Si? t-t _sjt`1c,(a,JJ ZO S25 7^7 37 -7 3cC) NAME PRESENT ADDRESS TEL. # CONTRACTOR: �-� E`�© 9 L 73ei g O (3 NAME MAILING ADDRESS TEL.# I -Residential ❑Commercial Est.Cost of Construction$ cr. C'Y")O t "-- Home Improvement Contractor Lic.# 13 2, y 5—L^/ Construction Supervisor Lic.#C S+RF.i -C.C.0C T3 Workman's Compensation Insurance: (check one) ❑ I am the homeowner X 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 (P Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( Leplacing like for like Pool fencing *The debris will be disposed of at: y .,--(/i,L.c..4L4j Location of Facility I declare under penalties of perjury the statements herei ontained 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 o on of my lice for prosecution under M.G.L.Ch.268,Section 1. / �y Applicant's Signature: Date: 7 ( 7- Owners Signature(or attachment) n, `�---\ Date: A 1 ` 1 I 7 Approved By: ,....".�+ Date: 7 - i' ^ 1 5 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No . The Commonwealth of Massachusetts a ;. -;,_ _ L Department oflndustrialAccidents A- 1 Congress Street, Suite 100 = �_ Boston, MA 02114-2017 Mr: .., 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): 3 7i_.g NC'GS ii.eZ � (vi) Address: City/State/Zip: Phone #: 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 2aI 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 5.1:1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ROther S , _,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. Tnsurance 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 certider the pains d penalties of perjury that the information provided above is true and correct Signature: 7Date: 7- / 2- -1, Phone#: J�O 7 c3 17- 5 3) 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructionSit{ Wietc1 &2 Family CSFA-060653 14 F.xcpires 03/20/2021 CHARLES A HOLMAN n 9 MAY LANE' SOUTH YARMOUTH MA*9664 Commissioner 44..,c.(// --- ... I Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Eftgistmlign Expiration 132454 04/09 2021 CHARLES HOLMAN CHARLES A.HOLMAN 9 MAY LANE lJ la. S.YARMOUTH,MA 02664 Undersecretary