The URL can be used to link to this page

Home My WebLink AboutBld-20-003278 r" Office Use Only Y •YARD • �L�iK O . `xN ` . H 'Amount MATTA n cscJ "1 Permit expires 180 days from {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 %Ext. 1261 CONSTRUCTION ADDRESS: Yl &/ Ae.vaiV ,E '/ ?./IJO(2�j " ASSESSOR'S INFORMATION: Map: Parcel: �� 1, _ OWNER: e z .�2 E.2 4 G.. /Q�'.� �J� Cam/ S —/`4 fn�D.2z �-L- 6702 9/6 NAME PRESENT ADDRESS TEL. #4/O/j96-As 7 CONTRACTO c5 K Cvg 2O6j Ce rc' = NAME MAILING ADDRESS EL.# Sb8` 4?-57� esidential 0 Commercial Est. Cost of Construction$ 3 erZle--, Home Improvement Contractor Lic.# /741 81`.3 Z Construction Supervisor Lic.# /0 3 L Workman's Compensation Insurance: (check one) -2-m I am the homeowner ❑ I am the sole proprietor At have Worker's Compensation Insurance 'rx. Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration /-� (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares /C✓ 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: De//!'J/Q.— 'A/1/7" Location of Facility I declare under penalties• .- ' ,at 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 ca - or denial or revocation• m •r prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature attachment) --�, ;'� Date: Approved By: Date: I,-' / -/5 Building Official(or desig ee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No ❑ Yes ❑ No The monwealth of Massachusetts Department of IndustrialAccidents i /7, 1 Congress Street, Suite 100 Boston, MA 02114-2017 47 °��IMPwww.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): sca/4 T p� t i- Address: 20 C Cede./t_ 7?..( City/State/Zip: -.7 kfr//r/IC /41d 42( hone 4: .SD -2-2-/ F's" 2— Are you an employer?Check the appropriate box: Type of project (required): 1.D I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 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. I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 E 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.E 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.t X14�6.- We are a corporation and its officers have exercised their right of exemption per MGL c. Other e�FlQi r�'f 02,§i(4),and we have no employees. [No workers'comp. insurance required.] i 1 de ed,4.// ��,'u ii *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: 9421�fj�z/i jegg/, j / City/State/Zip: /21,¢ Attach a copy of the workers' compensation policy de ion 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 certi ins and'ens of perjury that the information provided above is true and correct. Sig re_; — i Date: /2--°1 — Phone#: 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#: ✓its tooireir0f1C0etctuaa Cy.✓u[iCLwtccitctoeccv t� Office of Consumer Affairs&Business Regulation ��vJ) Division of Professional Licensure ` HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards TYRE Individual oonstr.4c11614%6Joeyvisor Registifitiork xoiratioR " !t 05/12/2021 CS-103622 yy * tpires: 03/19/2021 ROBERT SCO ROB` ROBERT S J9NE ' ) 206 CEDRIC RD 116' • AidCENTERVILLiJM ROBERT JONES 206 CEDRIC RD �-u J �GG. it h y it CENTERVILLE,MA 02612 /NS t Undersecretary . j Commissioner A /