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HomeMy WebLinkAboutBld-20-003834 J OItice Use Only t: At '.` 'Amount = *... .mvo,ip," 'Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 i N- f .-t6r2.) (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: 4 en NciV 1p 4 -NRef, ASSESSOR'S INFORMATION: Map: ,� Parcel: OWNER: -. )./� t-KweLL 4- 4 kA 0 ( L I jO �C31 NAME PRESENT ADDRES TEL. # CONTRACTOR: A mes I Vc(---- )L \ ®d l/3{gs5' 4(ue4 Jif liS So' 7 ZS 3 J I / NAME MAILING ADDRESS TEL.# 14\Zesidential ❑Commercial Est.Cost of Construction$ 1—S ` Home Improvement Contractor Lic.# l ! 3 3 I Construction Supervisor Lic.# GS" 0 04 9 e171 Workman's Compensation Insurance: (check one) ❑ I am the homeowner LI am the sole proprietor ❑ 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: /V W V( /' 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 denia rev c o of cense and for prosecution under M.G.L.Ch.268,Section 1. ,,//�� Applicant's Signature: Date: ' J XJ / /ZDOwners Signature(or attachment) yokDate: j Approved By: Date: I - 1' t•d Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes a No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts ' _ r Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 5.,- 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): 30, , ( p jc, . Address: c- © IA (, 1--S GC U eK. D City/State/Zip: D:5NWI S VVL 0 Z D 38 Phone 4: d- 7 a. r3 ( 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.;'A I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling .ny capacity.[No workers'comp. insurance required.] 3.❑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 6.❑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 required.] *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. n: 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 rti u r ains and penalties of perjury that the information provided boy is true and correct. Sisnature: t Date: / 2 Phone#: SOBS `72 v 3 sl 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ✓/te ooyrm,onraerzare,t ✓voridevuvKLJeGCd Division of Professional Licensure Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards HOME IMPR /EMENT CONTRACTOR Cons rust it iSpa.rvisor Individual RisjittiR# Exoiration r- 1 5! - �� 09/30/2020 CS-064947 spires:08/16/2021 =-a JAMES M MONOUCrt R, f JAMES MCD( (D 599 OLD BASS RIVER DENNIS MA 0;638 JAMES M.MCDuNOLIi % 599 OLD BASS RI�ERJjtb DENNIS,MA 02693 Undersecretary Commissioner • • i" •