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Home My WebLink AboutBld-20-002378 ° R I RECE ! VE_D - .002 7� _� l„ [.$ 7 2U19 ..Amount OCT - °'"°""°"9 E"`. i Permit expires 180 days from -' ,2t_NFL. I �o,'',. j issue date Y _ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 4-1- 31 m is L V f r.-U AO_ Soj)TK Y�g.-n )1"Y ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 241 /F D,'nsd,I.r-,_ /7 2 q,r �,v� iffr11',vis , i4 ��6p��og -�3 -S�'� Li NAME PRESENT ADDRESS TEL. # CONTRACTOR: le-)ck rat Dy t ChFlf-Thf/ < -6 7 - tf 3 C> Q Z (Q T NAME MAILING ADDRESS TEL.# PeResidential ❑Commercialo Est.Cost of Construction$ 3/ #� f U O , c t) Home Improvement Contractor Lic. tldl-644— iV(0R�iier ' Construction Supervisor Lic.# o6 f j y( Workman's Compensation Insurance: (check one) 3 /2 f p9—raam the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance l� Insurance Company Name: wt ANY Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares S 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: Y,4 A Wt j) U T l-f 0 U Vbt io Location of Facility I declare under penalties of perjury that 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 cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /��Q Date: /� Owners Signature(or attachment) /'C j�� j ze Date: `e '�� `I Approved By: Date: / Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes El No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No \ The Commonwealth of Massachusetts r Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 M�5�•'4y 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): / 14 L 0, r4 11_• iJ v r Address: P - 3 / Gu i✓ L v; ie,t) s v u ;i-L yPfie mera-r i le City/State/Zip: c1 by Phone #:�,-o 0 — A 3 7 —,re> Are you an employer?Check the appropriate box: Type of project(required): 1.❑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.]t 4.E-I am a homeowner and will be hiring contractors to conduct all work on mY property.PTt)' I will 10 ❑ Building addition 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.❑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 t p"/(> 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. I.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 pains and penalties of perjury that the information provided above is true and correct. • Signature: 1gaaC E Date: !c/ —� 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#: Division of Professional Licensure Board of Building Regulations and Standards ConstroCttti adp,rvisor CS-001995 E;�ires: 03/23/2020 RALPH DIMONTE -72 "tt 17 RABBIT LANE #" HYANNIS MA 02401 �` b �O1(N'1.10.1° Commissioner v"�