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HomeMy WebLinkAboutBld-20-003589 Of,YARI Uncce use only ZQ • 1 Permit# r p(� y !Amount S D G .,ATTACH C3t'. I �,l`°ft«•«°'�teed I Permit expires 180 days from tissue date {3 RI, • EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ; i Yarmouth Building Department �� � �� 1146 Route 28 (v South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: q- G,w , RA, `/c r, U i .)---\;, ASSESSOR'S INFORMATION: j , Map: tin Parcel: _/] �^ OWNER: M&rSV/ 4 dsS (�Id-7 eo0f • 0241lc ii-TEL.��-3AP"FJ o b NAME j JPRESENT RE S ,�Q ,o ` � # z� CONTRACTOR: tJ t C� Cs2 0I i ( I S t © C kf O d ked eOVI v1 i? ' yA L d t,g,o t ,Dm NAME MAILING ADDRESS TEL.# !Residential ❑Commercial Est. Cost of Construction S 1 6 00 Home Improvement Contractor Lic.# 16 U 0 Construction Supervisor Lic.# 07 7 6 3- Workman's Compensation Insurance: (check one) ❑ I am the homeowner A_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: # 1 I Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: AT 01 0 LAAN ---Cie&A"- e1 . 9 Van. . 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 tion of license and for prosecution under M.G.L h.268, ection 1. PP Signature: >i� ',---Cr ---- ;� Date: / 0� ‘ ii Applicant's L''�f' � "1� j / [' Owners Signature(or attachment) / Date: i D'--✓.0 —` 7 Approved By: �.64-- Date: 'il\-- U6 -15 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 Q No 0 Yes K No "` =. The Commonwealth of Massachusetts Y 1 MtBWE 1 Department of Industrial Accidents Let, l- 1 Congress Street, Suite 100 p=�i `= Boston, MA 02114-2017 `,N„5�•` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 13 c.0.. ! I l !/S Address: l 6 Cro 6/.2' rir,) 1),,,,,f WC1� l City/State/Zip: I�f a , 71(.,_ c96o / Phone #: 5 C-aVo —p).g• Are you an employer?Check theJappropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. Li New construction 2.(S I am a sole proprietor or partnership and have no employees working for me in 8. [I] Remodeling any capacity. [No workers'comp. insurance required.] 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 10 0 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.E Electrical repairs or additions proprietors with no employees. 12.—Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance. 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.. Other 1 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 41 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: g fl..J./1 (c(.t' . City/State/Zip: yet/yam v?A 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 certi under the pains a nalties erjury that the information provided above is true and correct. Signature: Date:/ • Date: '-f Phone#: S-6F-Dr(� t D p 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 4: • i:.. . Commonwealth-of Massachusetts; e ®� Division of Professional Licensure- Board of Building Regulations and Standards / Const` 0 t pFrvisor :c �! CS-078687wh. s )i s�pires: 05/29/200 2 t/ BRUCE P MIt f:,S I1 , • 16 CROOKEDP+ANp - • '' HYANNIS MA s2�¢1 k N(----- t• Commissioner C, r�„_ Office of Consum • er 8 Business n Regulation HOME IMPROVEMENT CONTRACTOR on TY: :Individual .....,,it. 09/24/2020 • BRUCE MILLS#y' _ BRUCE P.MILL9t : 31 , 16 CROOKED Pp a " `e---- HYANNIS,MA 0260f,. 0 Undersecretary