HomeMy WebLinkAboutbld-20-004027 O1—yRR uuice use uniy
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.40 .PPermit#r Amount DO '1
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Permit expires 180 days from
{issue date
BL U-40Z; RECE-IVED1
EXPRESS BUILDING PERMIT APPLICATION'
TOWN OF YARMOUTH JA N <2 2 P r '
Yarmouth Building Department
1146 Route 28 BUILDING DEPARTMENT
South Yarmouth, MA 02664 By.
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: Yi 'n.e 7e '1 / , l'et/v.,,<X,7-7/.40/i
ASSESSOR'S INFORMATION:
/ �� Map: C Parcel: /,r� g?
OWNER: S�( 6,/-4.o -6t J a wf-c. ( / `- -Zr;7,1-
NAME � / �,� /JPRESE/NIT ADDRESS TEL. #
CONTRACTOR: . '')12 1 Ale/t11.2 /�"41-,c i 4-0„i t'2C F J - Y7-J22J
' / NAME MAILING ADDRESS TEL.#
0esidential ❑Commercial Est.Cost of Construction$ 5D U
Home Improvement Contractor Lic.# f ICl/V Construction Supervisor Lic.# C-i"-//tf ??;"
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ I am the sole propr tor have Worker's Compensation Insurance
Insurance Company Name: fl Worker's Comp.Policy# 2 td C&I6 TIP
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: 4416(/ 0i/ek—2 "eitioit it/ 4.4&,-,-.4,....„
Location of Facility
I declare under penalties of perjury tha he statements herein c.• ed 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 rev':. ion of n license.•-- .•.. -cution under M.G.L.Ch.268,Section 1.
Applicant's Signa . td ^// Date: /��,0G,,u
•
Owners Signature or• - .chment) Date:
l �
Approved By: . . Date:
_ I ^ 41..— l 1•./LC
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes No Flood Plain Zone: 0 Yes D. No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ 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�•''y www.mass.go v/dia
'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information { } PIease Print Legibly
Name (Business/Organization/Individual): /Cir
Address: p �` 222
City/State/Zip: i,Pl,,,; P/ 4'i' Q6 ' Phone #: .Jo7-2 Y-799j'
Are you n employer?Check the appropriate box:
Type of project(required):
I. I am a employer with 2 employees(full and/or part-time).* 7. ❑New construction
2.E I am a sole proprietor or partnership and have no employees working for me in 8. emodeling
any capacity.[No workers'comp. insurance required.]
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 El 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
b.EI I am a general contractor and Ihae hired the sub-contractors listed on the attached sheet. 13.r]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.
r 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: /I IVY 144
Policy 4 or Self-ins. Lic. #: 24 �y/GAL T,V-e- Expiration Date: /4/•-°=""4"
Job Site Address: 7) (4teue7G'I"d City/State/Zip: Vt(A-si 1. 4pki,41t,),,,26S%
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 nd r the pain an penalties of perjury that the information provided ab ye is t ue and correct.
Signature: / ` Date: j 22 2°'?
�/Phone 4: Y22J
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#:
/ Office of Consumer Affairs&Business Regulation
• HOME IMPROVEMENT CONTRACTOR
T?#E,:Individual
Restis1611211 Wiir_dign
03/20/2021
• SCOTT REID'1�t t ( "
DB/A SR PLUM Ii "t `,
SCOTT REID "� kf � ^r •� eli`
ds
36 CROSS ST
fr. HARWICH PORT,MA 02646 Undersecretary
Commonwealth of Massachusetts
` t Division of Professional Licensure
' Board of Building Regulations and Standards
• Consl� Ctir3lti�pp`rvisor ,
CS-113285lt, ;w 0,pires:08/10/2022
SCOTT L REP ' rv»' ,,
P O BOX 222r; :pia" j-
HARWICH POW MA 3
/ y , ``
gi
Commissioner /1-14;.4‘4>/14"-"-'4----
.
THE
HARTFORD April 19,2019
Account Policy Information:
Agency Name COMPLETE BENEFIT SOLUTIONS/PAC
Agency Code 76250837
Recipient Information
Scott Reid DBA S R Plumbing
PO BOX 222
HARWICH PORT MA 02646-0222
SUMMARY OF INSURANCE
Account Policy Number Policy Premium
Policy Recap Term
Worker's
Compensation
The Hartford 76 EG AC8SDO 02/18/2019 to
W $1,727
Fire Insurance 02/18/2020
Company
Sum of Insurance
SECTION S: CONSTRUCTION SERVICES —
5.1
Colictrnction Snperc is r License (CSI_) --
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. SECI ION G tikOIU ERS'COMPENSATION I NSI RANCE AFFID:1VTf(\LG.L.c. 152.§ 25C(6))
V.orkcrs f i ,c i ii ltia i+ac a t1i1 1F11 must t h'Ioi pee tee and suhn11ttecl 1Vnh this a p]e._,ii n t 3 1'1C'to itr o,:
1`: di-I:d is 'A Ili r 5 )t _:: e d.n:dl of the ksti:.nce.r. he h!;..LIi:i pe11n.r.
SECTION 7a:OWNER UT1iORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I as fist^, :11C tlb p rL er S C'� et her:.by a cizc "l
to:.C:at.C771 t:tf7d ..t.,_a:Cl.rt.•:S,.1 IutC to ttar.t as 1Qri22d J. this hU11,1111= 1tC.111:t S;'i`.t li:`C-.
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ZI 4goarr 202-0
SECTIONAGENT DECLARATION _
Fi t':1 tr.;; il'w e 5ait it• 1 Isereh e.31 under ii n.:as au(:p.:::31tI of itet it?. that;ill of Inc IL!-v.m'1,rvi1
(.011-'111Q._ '. u;t:. rl'c1IN`P:s and accurate:tJ.i t 7 ;`1 true !-es_of( , knowledge end L,tiiel st.Ldinc.
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NOTES:
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