The URL can be used to link to this page

Home My WebLink AboutBld-20-003668 i. ' Office Use Only ' Q•- Permit# O ++��. C 3 D y. •Amount ` f( Permit expires 180 days from lam) -Zi)l3&0 k issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1 i 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: A4 g"..f f ie- Do-ye_, Y vi AL r7' ASSESSOR'S INFORMATION: �.,, Map: /2/5 I Parcel: /3 3 OWNER: l-ne ,( tAI w.r .24 gI'i4/Lt 7)kive_ NAME ,/ 1 PRESENT ADDRESS / �/ ,y/ TEL. # Q CONTRACTOR: 1, -H •VIII' Cea t1 /1 &/Ti/ /DkVDk Jed• S - At-04U!A 7- —2/Z— /32 NAME MAILING ADDRESS, TEL.# Not‘dential ❑Commercial Est.Cost of Construction$ /7,077D Home Improvement Contractor Lic.# /9 2-cm Construction Supervisor Lic.# C S Q c Workman's Compensation Insurance: (c eck one) `\ I am the homeowner 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 3 6" ( t temove existing*(max.2 layers) Insulation Yw 114 Old Kings Highway/Historic Dist. ( VI-Replacing like for like Pool fencing *The debris will be disposed of at: Alarto'a 0 is C-1 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. 1 understand that any false answer(s) will be just cause for denial or evocation of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: /2//-r/6 Owners Signature(or attachment) t.--/ Date: 'al 141 19 Approved By: N Date: /£ "l 3, 4'/? _L Buil . O I(or designee) AIL ADDRESS: arils, / ,,�,sj,,v1 h Cell ( co„,,,,sit.b e. 'Zoning District: 44o 0/�'"' ," Historical District: iYes No Flood Plain Zone: Yes /No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes ✓ No . The Commonwealth of Massachusetts ► =' r Department of Industrial Accidents .=a__ 1 Congress Street, Suite 100 ` _ Boston, MA 02114-2017 ,: 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): C •/`lA- t t e .-►.i `P I C - Address: 17 S f i%f &-T k City/State/Zip: S.ykr14& 4Jzrr MA- UZ 664 Phone #: 1 i4-2/2 -0 7 U Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 PI 'ng repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs The e sub-contractors have employees and have workers'comp.insurance.: 6. Ve are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]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. tContractors 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: &/11/;Tv�,�d Date: AP/2-16//47 Phone#: �q-- •1e2,041.? 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 ®3 Division of Professional Licensure Board of Building Regulations and Standards Constructbn'Supervisor CS-095633 • E pires: 08/20/2020 CHRISTOPHER A V r 17 STILL BROC RO SOUTH YARMOUTH M, Commissioner C/"— t„2/. ��Ju./n:c✓l Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation ReaisDu isn Expiration 182090 05/17/2021 C.A.VINCENT,INC. CHRISTOPHER VINCENT 17 STILL BROOK RD SOUTH YARMOUTH,MA 02664 Undersecretary