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Home My WebLink AboutBld-20-004598 Office Use Only ( .01'.YAR`� C O . - ' . H Amount ` A'T C ESE I,4 i °`°+•.•....-c� i Permit expires 180 days from -- i issue date EXPRESS BUILDING PERMIT APPLIC ler l N '._„ TOWN OF YARMOUTH �; Yarmouth Building Department .k P-7t4 2` ' 1146 Route 28 South Yarmouth, MA 02664 j .• �,c (508) 398-2231 Ext. 1261 _ rl` -- " -' �;� f CONSTRUCTION ADDRESS: I I L 0 1 1: Ol 01 Stet1- ASSESSOR'S INFORMATION: Map: Parcel: \�j OWNER: .:Lv2 . (ki C ' ,0y: (-2 61- �:;. YA(M„y,t, tit4A cZ “,-( (.5-qi) Ito— SAS: NAME PRESENT ADDRESS TEL. # CONTRACTOR:/1 C'}V)1 7 1 0'U / �it C- 1 V V C i le t r J•yftilil0 -s O Q '"3 L4 3 7 NAME o MAILING ADDRESS /' TEL.# 47'Residential ❑Commercial Est.Cost of Construction$ 1 0 II Home Improvement Contractor Lic.# I 4 t)1 9 Construction Supervisor Lic.# I CA 1 ,-51 Workman's Compensation Insurance: check one) I am the homeowner VI 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 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: I DV) 0*- y6,,Trovih V1N me 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 prosecutio under M.G.L.Ch.268,Section I. Applicant's Signature: ,r Date: )--^.)-0"30 Owners Signature(or atfachment)__ / Date: l Z�' LitZ'D " Approved By: e Date: 2—2c, - Building ici r desi ee) Elv DRESS: 001 Zai�s 3 Wmu 1 '. 'f Zoning District: I Historical District: 0 Yes E No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 2 No 2 Yes 2 No The Commonwealth of Massachusetts 1V Department oflndustrialAccidents • 1 Congress Street, Suite 100 Boston, MA 02114-2017 IMP 5•''y www.mass.go v/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): N V)..toLcts a Address: 3c4 C,c P1ciN We(iti'"'�� City/State/Zip:S,l/g1^Pl(k/i MA, 61461f Phone #: Mpg_ 3 6 3 77 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. n Demolition ❑ y [No workers'comp. insurance required.]' 10 E 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.Q Plumbing repairs or additions b.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 .❑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. 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-contactors 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 r 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: Date: 9=,-B-)-o Phone4: So2, - 1)64-$3`�) ni Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone n: (� Division of Professional Licensure `mil Board of Building Regulations and Standards Office of Consumer Affairs&Business Regulation Const lOtt$rr ItUUprvisor HOME IMPROVE RENT CONTRACTOR TY Nndnridua1 Reais `, Expiration CS-108927 _ f c�ires: 07/17/2021 Q1/04/2022 NICHOLAS BEADY t ° f, NICHOLAS G. 84 CAPTAIN WEILE •l.i+t SOUTH YARNOi UTH $ , FA ' // �� , NICHOLAS G.BR r ,* l'�)1N�.1 84 CAPTAIN W EIL l*RO; SO.YARMOUTH,MA 02664 Undersecretary Commissioner Ajo..J1/ • • •