HomeMy WebLinkAboutBld-20-003531 ?Ottice Use Only
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EXPRESS BUILDING PERMIT APPLICATI�QL�L ,
TOWN OF YARMOUTH ' 'a P 7 7" 1 3 f i-
Yarmouth Building Department
1146 Route 28 D---, 2O1 i
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 j ' ((: ,, , .( 4
CONSTRUCTION ADDRESS: -;2--`A OUP r\Ak w S l
ASSESSOR'S INFORMATION:
l h Map: G \ Parcel: ' ,Z �?�
OWNER: �l IL(mDA-k m�ihcx 1 IS-6 Cr L (C t \
NAME PRESENT ADDRESS TEL. #CONTRACTOR: Ro. 02.frt- SC-0l 1"�,. A p AtoC SA `--nA/ b t is v A
NAME // MAILING ADDRESS TEL.# 0�-333— Glen
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❑Residential Zommercial --1 Est. Cost of Construction$ -_0 1 0 O 0
Home Improvement Contractor Lic.# 1 .5 Z S e 5 Construction Supervisor Lic.# O 1 e 6 \
Wor kify,Ci
ompensation Insurance: (check one)
the homeowner 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 H Replacement windows: # 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:
114tiP'xOvT.. Lp.i.. .\--A
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 revocation of my license and for pro cu nder M.G.L.Ch.268,Section 1.
'\"C'Applicant's Signature: ( e^-'` Date: ` / ZO
Owners Signature(or attachmentL(�c'L. Date: I 2/ 2 d ( 2 0 /9
Approved B : Date: J/'— O ')S
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Building Offici (or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes LE No Flood Plain Zone: 0 Yes '0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes ❑ No 0 Yes ❑ No
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street, Suite 100
' Boston, MA 02114-2017
•`' 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): C-LA SSIC,. I31., cc,4Ns r \
Address: Li I A c c „NI oo SA .,\/A.y
City/State/Zip: (nAt>`SToku& Y\��` 1 t Phone #: JO — `OZ('S— a1 k�
Are you an employer?Check the appropriate box: Type of project(required):
I.❑I am a employer with employees(full and/or part-time).* 7. New construction
2. ‘,o am a sole proprietor or partnership and have no employees working for me in 8. J 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.]` —
4. I am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 — Building addition
P property.
ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.[II 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 _t
6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other E X��f‘U ti ` m1`\
152,§1(4),and we have no employees. [No workers'comp. insurance required.] R .p4 t(NS
*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: C L Date: 1Z/EO l kct
Phone#: 5 O(S j� '1 C6
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#:
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ii : 6pires: 10/09/202'
ROBERT C SPOTTI
41 APPALOOM WAY ,1 z 7 t ,,"
MARSTONS MILLS MA.0/648 .,'••!-: '1,:,° AI" '''''"
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41 APPALOSA Vki A __....,„
Undersecretri -i•
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MABSTOBNS Mtl..L9,MA Uzlogto
Commissioner
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