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HomeMy WebLinkAboutBld-20-004322 •o�••YAAti Office Use Only `ti Permit# 0 .,,r, . iv... Amount ++at• cj. Permit expires 180 days from i' L 13,),, issue date EXPRESS BUILDING PERMIT APPLIC W _ t V E 4 i TOWN OF YARMOUTH ° F Yarmouth Building Department `� 'f ` li? F � 1146 Route 28 . �.-..� -,� -. South Yarmouth,MA 02664 1 1!` J ___......1q' t (5 0081)`398-2231 Ext. 1261 CONSTRUCTION ADDRESS: S4 �`I I ,c t4. 1 V "(.SSI VW i ASSESSOR'S INFORMATION: �`� Map: / lir Parcel: (q/ OWNER:li/ l l . / . et�h��d vk P.0.A()y Guy (4 t(bird/4&4 ®rem ? e.-ruo- f3 NAME P ` PR ENT ADDRESS / TEL. # CONTRACTOR [OK e ql dr. -`t 1 •E• DD SS 6((qv, ©O"&: so (D.r1/f) NAME J MAILING ADDRESS TEL.# ?I‘ '' esidential .S'004 0Commercial Est.Cost of Construction$ !o Home Improvement Contractor Lic.# f 006 (�/ Construction Supervisor Lic.# o3 / 7 1 Workman's Compensation Insurance: (check one) I am the homeowner - I am the sole proprietor Xhave Worker's Compensation Insurance �1 Insurance Company Name:/4 At&aro( "`4 C©f Worker's Comp.Policy# r t V CO&A 6 et WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Replacement windows:# Replacement doors: # lVi Siding: #of Squares p p Sa rA` � V� t 1 Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation 9*�D afro, Is_,,_OldUKings Highway/Historic Dist. ( )Replacing like for like Pool fencingLA u milt" The debris will be disposed of at: 1V4h r X0-1 G !.ktr Q°1 r(42414S 4't4— LOCS@nof Facility I 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) VA/q, will be just cause for denial or revocation o license i. U,•'• ecution underM Ch.26 ,Secti I. Applicant's Signature: WA fAlt(7/1- L4/ r Owners:ignature(or attachment) ` 1 • C a{ ctia'kAil ' v KIia-fi ._ Approved :•. i :� _ Dat : � .O Building O/,'al ,/esi_ ) E • • •DRESS: • 4 , ril= Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No • ,-.,,. . -7-i I _ ____ __ -----iv------cl,1 11 A? -'__i______.freo/___141_L_TA-477e7-______ __ ____-_._____ __________ j . . ------—z--.1)---c.---5----,--,7-, i i i----rj -e T. IPAilii f4 WalM-4'V 4 p II . The Commonwealth of Massachusetts It__ i i—A/ Department of Industrial Accidents _.=ei q 1 Congress Street,Suite 100 ?`s,,� `' Boston, MA 02114-2017 -ftYf www.mass.gov/dia Imp Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Legibly Name (Business/Organization/Individual): 7 t4-q �/( I1 f'c/ . r ,nV Address: to. � , d )( ( 3 c% City/State/Zip: �� Phone S8e-d-Yer-1/25 1/ Are you an employer?Cheek the appropriate box: Type of project(required): I.[Yam 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. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑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.❑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 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that rbirs 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.0 (- �V"� Cc nssurancance Company Name: � t Policy#or Self-ins.Lic.#: ,`3--"V C-6 5 )(d Expiration Date: VV?"(9 /�Job Site Address: , /V l � f v" 1 City/State/Zip:'-� c 1 / `)J- 0, Attach a copy of the workers' compensation policy declaration page(showing the policy numb and ixpiration 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 unnddeer t e airs and pen, %. ,f perjury at inf' a, provided above is true d e o f -ae ill- fl! "t ��� 4,,,a ��� : �'V Signature � )�{e• a.., Phone#: . dVd— ,i Y 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#: na Commonwealth ot Massachusetts Division of Professional Licensure ‘ Board of Building Regulations and Standards Co nstructibn'Supervi s CS-037989 Expires:09/11/2021 THOMAS HAGUE,Ill PO BOX 1394' - ORLEANS MA_.02653 Corn missioner onice HOME IIIIIPROVEME of6w4.71:onsisimerAffairs&13e °SS ssin _Registration wild for individual use OM NT egidati" Boainr„.1).._LTY*.\cCIMOraliOriC°NTRACT°R iratb°f"ASnOUrt011°1 eXP RaCen dat retuY s zahmun 00:0:7 the TOM HAGUE,iM-: :::77._°6/07/2020 Consume Affairs and susinessmRtzwation Boston,MA -02109 TOM F.HAGUE, 48 BIRCH um 6.9-CrEL a gnatuf MA 02631- o " No: BREWSTER, valid Undersecretary