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Home My WebLink AboutBld-20-003522 iY.eikti‘ Office Use Only 0 , ;, ' y * '(� ILL' . N '' 4• lAmount i,Permit expires 180 days from t issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 e1� S era CONSTRUCTION ADDRESS: 3-1 C lxJ E.I AN3 j A , 1,3 t,5, qA.,,,,,,,,,,, ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ,,SI\ . Dl 3-/ et,-VGl .I.At, ii,qA-O_AA 0‘f NAME PRESENT ADDRESS 1 , TEL #.5 g 36i, 6-ig. 7 y I CONTRACTOR: . t-LA v.. 'W-tAJ C> \tV i _ P-i.11 tli + 'to M U C?-fA :MA L j` j 1_� NAME MAILING ADDRESS ` TEL# P. t'Residential 0 Commercial Est Cost of Construction$Z$50 ,�,� .-'mil Home Improvement Contractor Lic.# 1; 1 Construction Supervisor Lie.# C'C% (b Workman's Compensation Insurance: (check one) /� 0 I am the homeowner 0 I am the sole proprietor 4-have I have Worker's Compensation Insurance Insurance Company Name: r(.#: /11 ► Worker's Comp.Policyx ' LUCK "l U s-) L./ I j WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # / �/Roofing: #of Squares 6 ( d )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing "The debris will be disposed of at: LI+TD-N '( :=ilsi3C-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. I understand that any false answer(s) will be just cause for•. ., 'on of my,,license and fa } ' n under M.G.L.Ch.268,Section 1. / I C3 Applicant's Si: ., L Date f Z ( c l l Owners Signature(or attachment) Date: Approved By: Date: /2 ' .2v —/9 Building vial i ee) EMAIL .RESS: Zoning District Historical District ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft of Wetlands: 0 Yes 0 No 0 Yes 0 No • The Commonwealth of Massachusetts it ^� i��4'1, Department of Industrial Accidents • • • =_ ,n 1 Congress Street,Suite 100 • _ i f , Boston,MA 02114-2017 _, =i � wwwmass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �) _ lr Please Print Legibly VI,(Business/Org ization/Individual):� (JIS� g—C 1-t�V Address:9) e. h' P� 1411 . )±Sl c Phone#:� °1 1-tb'-t o Ci /State/Zi : Are you an employer?Check the appropriate box: Type of project(required): i.[ am a employer with C employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 lam a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 i am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[ of repairs These sub-contractors have employees and have workers'comp.insurance.: 6.Qoffi cers are a corporation and its have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box I/I must also fill out the section below showing their workers'compensation policy infommtion. 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 ispr Wing workers'compensation insurance for my employee& Below is the policy and job site information. ` 1 Insurance Company Name: [l.>r; Al‘k,C (0,C.Ak-- �" l ((1�, Policy#or Self-ins.Lic.#: b Z\).�b t4OS 5 V V lei Expiration Date:5 `\O` ZO Job Site Address:51 & Jt`l `^ 'l City/State/Zip: .1q.,Q.-riles"1ce( etk 02673 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 ce ,'" under the p. penalties of perjury that the information provided above is true and correc Signature. /9 43rQJ Date: J'2 - Phone#: ( ()C L{ 4 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#: • l D gL/22/220-/MbEeCGdi 4ACrr.'ioczoi et3W " Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual OLIVER KELLY Registration: 128957 • 8 RHINE RD Expiration: 06/13/2021 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 C' 20M-05117 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 128957= _-- 06/13/2021 1000 Washington Street -Suite 710 OLIVER KELLY -:'.` Boston,MA 02118 OLIVER M.KELLY 8 RHINE RD. i„(srn40t'(G-,ask' YARMOUTHPORT,MA 02675 Undersecretary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards • Construction Supervisor Specialty CSSL-099167 Expires:09/28/2021 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 • Commissioner ,t l Ar64*-1---