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Home My WebLink AboutBld-20-003470 , Office Use Only oo"YA 4: R c Permit# 0 i Amount L0 K�,4% <-`J� Permit expires 180 days from 4' IL C 1 (.7......,34-2D i issue date EXPRESS BUILDING PERMIT APPLICA Olf C E R V E 0 TOWN OF YARMOUTH Yarmouth Building Department DEC 1 8 2019 1146 Route 28 South Yarmouth, MA 02664 [ B-U ii �A R 1-M ENT (508)398-2231 Ext.)126 � ByT�' ` CONSTRUCTION ADDRESS: 4vt) 4 a(,.iti.L;//! , 6- / /14(()/ v ASSESSOR'S INFORMATFON: / Map: ;� Parcel: ) OWNER: (,'L(, k_'D� �IriG(�:J �(/�l! /i� L ��`�C'L '!''G �-l-31 ^ I J 1 NAME / PRES A DRESS `` - EL. # CON TOR . ' E /L ot 'i4/ ' a Dt;D. ~ \ d ti (,zAt` ICJ # —✓/ `z Cil r NAME ADDRESS �— TEL.# / rr/ esidential [J Commercial st.Cost of Construction$ I' CC • L'`' Home Improvement Contractor Lic.# r'J �� Construction Supervisor Lic.# Gi t.)) /, Workman's Compensation Insurance: k one) LI I am the homeowner am the sole proprietor :1 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: # 7 Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like - Pool fencing _ L_ (3/ , .., /7 *The debris will be disposed of at: (��('/Jd� t 6-:U•t,it%'K, (_ bit6(i L- / Location of Facility I declare under penalties of perjury that the state c d are true and o•tt a best of my knowledge and belief. I understand that any false answers) will be just cause for denial or revocation of m i f eection .G.L.Ch.268,Section 1. , Applicant's Signature: � Date: /)/# 77. Owners Signature(or attachment) ' 1 Date: /�//`f7 Approved By: J Date: � ''//1 —lc\ Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: 1 Yes ': No Water Resource Protection District: Within 100 ft.of Wetlands: Yes LI No L Yes I1. No The Commonwealth of Massachusetts = Department of Industrial Accidents 3itQl_ 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.go is Workers' Compensation Insurance Affidavit: u' ers/Contractors/Electricians/Plumbers. TO BE FILE WITH TH P ITFING AUTHORITY. AQD lcant Information ,;/ Please Print Legibly Name (Business/Org ization/Individual): , ,i�( Address: / // Iv City/State/Zip: 6'� Il r ii ° d Phone#: ) .' G' ^� '/ Are you an em er?Check th appropriate box: Type of project .required): 1.0 t a employer with employees(MI and/or part-time).* 7. 0 Ne construction 2 I am a sole proprietor or partnership and have no employees working for me in any capacity,[No workers'comp.insurance required.] 8. emodeling 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ 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.❑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.❑Roof repair's 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.#: 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 r-• •.-• der MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment, :: we as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A co. of, is statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify und:, the d p nalties perjury that the information provided above true and correct. Signature: Date: WC-- // Phone#: .) Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: c. Commonwealth of Massachusetts 1 Division of Professional Licensure `�J Board of Building Regulations and Standards Constr$t$ttr4 lttlpfrvisor CS-082931 _ Epires: 03/13/2020 / ADAM LABONTE m A * 15 PAYSON PI JH ' ,_ . W YARMOUTH MA 02 r. Commissioner CI.' (i------- . fuelenesiePull £L9ZO V N'H1f1ONIEIV l 1S3 M , 7' . 1 ,Hlt/d NOSAYd 9l ''1NO9V Wvav 1N3W3A0t lir f H-rind V/8/a IZOZ/LZ/60 a Nj r, Uope.1ldfc3 :::ygOlipog lenpNpul HO13V1:11NO31N3 WXOdd W13 WOH uoltsln5sy sssulsne R mew iswnsuoo jo**gm i"�