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Home My WebLink AboutBld-20-004649 a � Office Use Only • og`Y' R Z► c,., p. Permit# .11 y'2 • , Amount J v — � �.• ' Permit expires 180 days from 6`►J—a o— ( issue date EXPRESS BUILDING PERMIT APPLICATIOMR. EC E I V E D TOWN OF YARMOUTH i ! t Yarmouth Building Department IL R3 1 tz �;•� } 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 `'Y.... CONSTRUCTION ADDRESS: 3 Cal ASSESSOR'S INFORMATION: II�/II ��,�� Map: „ID Parcel: /g OWNER: �'�(/x/LP./n Q p � .�J? `�, rr`.�UAMERESENT.IDDRESS Atot I/` 7 4 2I2 -6O f ' TEL. # CONTRACTOR: C -V/h Ceh 7 /7_7177i R-rro /edf•, J.A.4444 a 7 /2-C3 q NAME MAILING ADDRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ l9 60 Home Improvement Contractor Lic.# /3 2eszjo Construction Supervisor Lic.# 4q Sb 3 3 Workman's Compensation Insurance: (gheck one) I I am the homeowner 14 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 0( ( /Remove existing*(max.2 layers) Insulation Old Kings Highway/HistoricDist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ' V vt,(/V e7 t/ - .S/ Locati 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 vocation ,f/my license and for prosecution under M.G.L.Ch.268,Section I. �7 Applicant's Signature: /✓--0,nd�/ Date: �!!�4[/Cti Owners Signature(or attachment)/ .401 Date: f -i/13-> Approved By: Date: ^kik — b,a Building Official(or designee) EMAIL DRESS: Zoning District: Historical District: = Yes i1 No Flood Plain Zone: = Yes = No Water Resource Protection District: Within 100 ft.of Wetlands: Yes ❑ No Yes _. No i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructibn`Supervisor CS-095633 p i res: 08/20/2020 A CHRISTOPHER A wittoor 17 STILL BR00)K RO ' SOUTH YARMOUTH MI1 2S64 ritYr<< Commissioner C Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Reaisbelien Expiration 182090 05/17/2021 C.A.VINCENT,'INC. CHRISTOPHER VINCENT 17 STILL BROOK Rfl i -4',%' SOUTH YARMOUTH,MA 02664 Undersecretary . The Commonwealth of Massachusetts ► "=, -g/, Department of Industrial Accidents w —E,eI= t 1 Congress Street,Suite 100 a_?e�� Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): C. 4 - V! j/l_ce"1-j /inc. Address: / / S/?i t 4n k got- City/State/Zip: c,yt,Ypt,cal./ AA O2 f Phone#: 5q4)(2 - 0 9,K3' 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. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑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. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs Th sub-contractors have employees and have workers'comp.insurance.t 6. a are a corporation and its officers have exercised their right of exemption per MGL c. 14 Other ke ('7T oP 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 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: Zf 2//Z-6 Phone#: F74— 2/.2 —6138 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#: