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Home My WebLink AboutBld-20-003588 • • 0 H Amount °U - �°'"'•" E : LPe1t expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION - TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 :'r ' South Yarmouth, MA 02664 (�a(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 Ca e— ASSESSOR'S INFORMATION: ,( Map: Co,„ . Parcel: OWNER: �`� C ) 3 C Vi�L+..� Air.'✓L 2 35 ,17` - 'NAME / /4/ PRESENT ADDRESS TEL. # CONTRACTOR: Get✓','> I t r tar / CvU'''slylrc-� .��t Jt��S J.. 7"/$/u NAME MAILING ADDRESS TEL.# OOC7 esidential ❑Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# f $0 7 O Construction Supervisor Lic.# G$ e - '5i'0 Workman's Compensation Insurance: f�tceck one) ❑ I am the homeowner 1 I am the sole proprietor 0 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 / ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: /Cis Oh "' / /0f,+ .1 ,- 5' / yr 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 denial or re ation of my .c e and for prosecu• under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachment) Date: / 2 3 /F Approved By: \\ ,c. ..lam✓ Date: )1... — d�� ''�'41 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes No Flood Plain Zone: ❑ Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No "i=s6'\ The Commonwealth of Massachusetts r Department of Industrial Accidents 1 Congress Street, Suite 100 te Boston, MA 02114-2017 M ,�5�• www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / PIease Print Legibly Name (Business/Organization/Individual): (! ,./f��4ri Z �J Address: /U17 . .. ›i,, Z City/State/Zip:_r tti.-►,J /7 p,.1-C-I o Phone #: SOF 3G 7 $/ `r7# Are you an employer?Check the appropriate box: Type of project(required): I.❑ I a employer with employees(full and/or part-time).* 7. New construction 2. am a sole proprietor or partnership and have no employees workingforin men 8. ❑ Remodeling any capacity. [No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]t _ 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑P1 ing repairs or additions 6.111 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. o0f repairs These sub-contractors have employees and have workers'comp. insurance.t. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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: � �y Job Site Address: CC ��•t�� it ��'�— City/State/Zip: / '" �'{ - t ti /7/"® G‘, 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 der tl e pal andd penalties of erjury that the information provided above is true and correct. Sig Date: 7# nature: , Z( /- Phone#: s`D F 3 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#: „_ ,.......„„„ ..„.... --- - -y--7/ r g/ /4.A/n,-,4„--i2,0,, ir, 0, ei,- zee), Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 180782 CHRISTOPHER WEEKS ,,,,,,1 -;;;;;;;;;;=,,,r,:,J tt:az-=-',. '''',. ' 41':- f '''', Expiration: 01/06/2021 D/B/A"WEEKS” ON THE CAPE 26 NORSEMAN DRIVE S. DENNIS, MA 02660 '•'„'''' 7i5;"'Llt."-',..'El T,EF:EE7 f', ':?-:'- '',;:,-,,TEE•Eli/ 4','',' Update Address and Return Card. 1 0 20M-05/17 .Z... (61/t/ilerVii/V,i714/r",,,(,e14^).9.r1(.,6)e/4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TOE;Individual before the expiration date. If found return to: \ RealthiltiOrk . Expiration Office of Consumer Affairs and Business Regulation 1616:7827"....-', .01/06/2021 1000 Washington Street-Suite 710 CHRISTOPHER)WEEI<C7,-v.:. Boston,MA 02118 D/B/A"WEEKS!!' pistillit,:e*pg r CHRISTOPHER P:VkitiKt 26 NORSEMAN DRIVE,' -" S.DENNIS,MA 02660 Undersecretary N valid without signature Coriimonwiaitti of Massachusetts Divisio*:0f,Proteisional Litenture Board of Building Regulations and Standards Constr40i1,01attrvisor CS480040Atipires, V t t 120 CORtitTOPH*Fvl' ' „,,,,,, )f ,,, ,,,...APrill!Proo '4 ...', .,'; 1 suurN DE --' ,':',N,r,,3;!i.: „.. * /01W14‘ / ! ', titOrtdOtotioit;