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Home My WebLink AboutBld-20-001838 .Y�R !Permit# ..y ir O �` 'l • '� Amount�� 4O+ra.rtco^b f s 1 1 R Permit expires 180 days from {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH OCT it �� 2f]10 Yarmouth Building Department 1146 Route 28 C043/ South Yarmouth, MA 02664 /(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: f 3 6 Sk l/i v/q.i QG, 14,/e s - yam,/-k11 O ei74" ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 5os h D im,,i-c /3 6 Set//i v<=, R7e? EO> 3 y YY N —�— r PRESENT ADDRESS TEL. # CONTRACTOR: Play !i,Ai P(2 /30,& !396 -sl" O c s PO S f '?�7� V�ef/ NAME MAILING ADDRESS TEL.# 'esidential 0 Commercial Est. Cost of Construction$ /O�d D• DE) Home Improvement Contractor Lic.# /'70 '72 O Construction Supervisor Lic.# C C. 0r72 7„2-V. Workman's Compensation Insurance: (check one) ❑ I am the homeowner W'�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 ,' 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: gc-,'- (-±ci y (G d e-l" ' Location of Fatility 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: Date: l'0 A(/( 5' Owners Signature(or attachment) Date: /e// Approved By: w Date: `00'— 77 Building Off es" ee) EIMIAI DRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 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): Address: / 3 aj )fir,SC 44he i3ox 3 1t;) City/State/Zip: Mtir-sfe-,) I i,YA e26'/f Phone #: ¶o g 726 7( "if" Are you an employer?Check the appropriate box: Type of project(required): LE I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.S1 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. [No workers'comp. insurance required.] 9. [1] Demolition 10 ❑ Building addition 4.0 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.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�Other SiCfah t�e�,hce w�,�` 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box gl 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#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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct. Signature: J Date: 1 p I, ' 1 Phone*: Tad 7 '/` 7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstrtkCtt op4rvisor CS-078724Ejtyires: 05/06/2020 i ROY H TOLLA/ER PO BOX 396 i MARSTONS MILtn$MA"' jos IO/c 7-10'6 i r Commissioner Cl"" (g2e Cpane ww ea/,C,�C o/Cilazoackaea Offici of Consumer Affairs&Business Rsgulatlon HOME IMPROVEMENT CONTRACTOR TYPIodividual 1 # ; 01/10/2020 ROY TOLLIVER D/B/A ROY TOLLIVW1119141VMOCTION SERVICES ROY H.TOLLIVER 3512 MAIN ST#12 ' BARNSTABLE,MA 02630 Undersecretary Ili 1 � Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation.of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 i _7-750 '. Not valid without signatur I