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Home My WebLink AboutBld-20-001354— Y.. Office Use Only 1n a,. Permit# Q 'l, . y -_Amount .v rurr pi cs'-ftrea ne"A 6rd•' ( (� `'Permit expires 180 days from L _.. .:.,• 6 LV`2C,—�-(3J issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH SD:- 10 2019 { Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 ,/� ` �(508) 398-2231" rEx�t. 1261 CONSTRUCTION ADDRESS: / e. /f':m--ilei ifve.r 6 !L(fS��IfQ`�� O y .2, 9( ASSESSOR'S INFORMATION: Map: Parcel:OWNER: SJt/ e # 5 G16DLL-- O AV-N - �PRESENTBDS TEL. # n /� j�' CONTRA OR: aUfcic %'4 v ' d/I�!faK _/ 08 NAME • I ING ADDRESS T L.# �/" sidential 0 Commercial Est.Cost of Construction$ '- 6f/'7 Home Improvement Contractor Lic.# /0 0 � 1 / /tl Construction Supervisor Lic.# V Workman's Compensation Insurance: (c eck one) 0 I am the homeowner 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 Squaresc5/ 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: pvt,1 4,,,,,,thik Location of Facility I declare under penalties of perjury that j e state is 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, scald` of cense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ?/ram/� Owners Signature(or attachme Date: Q /7 Approved By: Date: lels )1'7 Building Offic' r d ' ee) EMAIL ADDRES • Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts ,i ► _W'11— Department oflndustrialAccidents ie'1- 1 Congress Street, Suite 100 •_ �_ Boston, MA 02114-2017 :. 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): „ 4 Address: fo, City/State/Zip: *q47'1---C7 in"- 07/6 01 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. E New construction 2.7 a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 3.0 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.❑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 requirecL] *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: �d Job Site Address: f 4Af/js'/1d 4'� City/State/Zip: .141%/ ' i i)u � '' '9- 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 c der t1 pains and penalties of perjury that the information provided above is true and correct. Sig Date:nature: 04 Po 1? Phone#: 'e-'1/ - 536 — 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Z.; Kwienewepeati,iye./A:a<marZe.sel.45 Office of Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: • ` Rrn estratrow Office of Consumer.Affairs and Business Regulation 10/26/2020 1000 Washington S -Suite 710. DAVID SILVA `� - Boston,MA 0211 D/B/A EAGLE MrEMENT ^ . DAVID SILVA612...Ccart-- gd) e. 69 PONTIAC ST HYANNIS,MA 02601 treta Not valid without signature y Commonwealth of Massachusetts OSHA. 11-006048425 Art Division of Professional Licensure .,°„ �+ Board of Building Regulations and Standards �rr.w> ttu.c.a.A...4edpe,�.me ;e.,ry,.„.„.y Construction-SUp i i�r Specialty CSSL-100924 Gjcp � lres: 09/12/2020 This card issued to: DAVID V SILVA .# ,89 PONTIAC ST DAVID SILVA HYANNIS MA 02601 - 5 Rony Jabour 4/3/2018 Trainer Name ---- Date of Issue Commissioner CL