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Home My WebLink Aboutbld-20-0029 g uux;e use only 9 �" • '• 1 Permit# O 114 . H Amount L \�� MATTACM CSEJ,� �`°'"""`°°9..... (, I'I Permit expires 180 days from ; :.... r ,\ .2C t (, t l issue date EXPRESS BUILDING PERMIT APPLICATI N TOWN OF YARMOUTH R E C F I V _ D Yarmouth Building DepartmentI 1146 Route 28 I NOV 2() 2019 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 Bu... 1 RTMENT / �/ By CONSTRUCTION ADDRESS:/4 v;v ,,rrZ1 Ci..v.3 �Y1rf . j S /ciEN,0Lyri•1 ASSESSOR'S INFORMATION: Map: Parcel: tin OWNER:IT124 r es -! ., 1-yr✓CN k 4 C u „re-( C,_„(), Lt3 . 5 I/' S1 - 5— C.&5R NAME PRESENT ADDRESS TEL. # CONTRACTOR:/ „'t ?U • ),( j 1 0 kixs i 7 k x„0S 7 O 8—8t�b- NAME 3 MAKING ADDRESS TEL.# J --El Residential ❑Commercial Est.Cost of Construction$ ?C)0 Home Improvement Contractor Lic.# I O /2 9 i' Construction Supervisor Lic.# /0//6,,7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner —n. I 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 Squares 3 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: Si--S Cx Cx, 1 -Sc. T N J C nl N I$ Location of Facility I declare under penalties of perjury that the statements herei 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 revocation of y lic se. rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: II }ICI I 19 Owners Signature(or attachment) - Date:.///q//y ' Approved By: Date: // //'" 1'7/l`' Buildin ci r desi ee) EMAIL SS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 '-.„5�•`'•4 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): /v,,, �o-T'E Address: 9' (J G j f U City/State/Zip: (4/ • A,;,,/s Phone #: —Q Are you an employer?Check the appropriate box: Type of project(required): l.E I am a employer with employees(full and/or part-time).* 7. E New construction I am a sole proprietor or partnership and have no employees working for me in $ -Z. 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.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on property.mY I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.111 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'com p. uance.=ins 13.E Roof repairs 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 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 4 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 unde ze ain and penalties of perjury that the information provided above is true and correct. Signature: Date: //))/// Phone 4: q' bg 6R- 0 4II 1-4 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 • Constructi\oYr"Sliplg.'Spir Specialty •CSSL-101165 icpires:09/27/2021 THOMAS M IITEJ 'j 1 P.O. BOX 1101 , WEST DENNIS,MA f)iSS-1:101V� Commissioner LN90-010Z f3 l VOS 'Imo unmet'pue ssaippy emepdn �{n tad '° a �� ? s • 1,1 P,0 OL9Z0 VW'SINNJO 1SJM :uol;e�ldx `," , �:t I.066 XO8'O'd 1-Z0Z/171/£0 3 ,} � r31nd'W SVWOHl 56ZI.9I. :uol;e�;sl6a� , 1 ' - lenpinlpul :adi(1 C� uoiie.gsi6e .1o1.oe11u Wewanadwi 9WOH 86 1,ZO S esny sSiw `uolso8 014 a;!nS -100J4S uoT6uiyseM 0001, uoi1eIn5eu sseuisne pue saiej4y iewnsuoo jo eogjo GGj /7-03, 2/-0-4617e/ G) L%��