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HomeMy WebLinkAboutBld-20-004382 I 1 . , ..40): " ..\;\ '''': :I' .1'..: \° (6 EIC E I V E 1D I- R , ,:Office Ilse Only i le : 24' i cFP 201 1 ! I Ainot4 LIAL -01) 1 ' I ermit expires ISO days from 14 *Ilk'2- i;--A F-(1-11i4 •PO F issue date 1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7...s-- Pa-m pArla f-ot ...,..._. ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1-Te IT w h-z-bb„...e....., 2_o eors fLk.kid& NAME PRESENT.141/PURESS TEL. # CONTRACTOR:j"-g-c: 1A)Attetyl_04_, ZO POS 11,./ 1-(kaviik -77+2_6)3-9(07 2-- NAME MAILING ADDRESS TEI..4 Miesidential 2 Commercial Est.Cost of Construction$ lac, O©v Home Improvement Contractor Lie.# /&5 0 5-3 Construction Supervisor Lie.# cc — /0 3 0/9 Workman's Compensation Insurance: (check one) : I am the homeowner -1 I am the sole proprietor have Workers Compensation Insurance Insurance Company Name: --Ige .1--/A X7/-01 Worker's Comp.Policy# 6,56:00e - 06-is-9/67 WORK TO BE PERFORMED Tent .._ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares S.— Replacement windows: # II Replacement doors: # y ,...,c.s SV,ac-.4'3 Roofing: #of Squares /-1 ( 412emove existing* (max.2 layers) Insulation 6v..iceg- bk/ Old Kings Highway/Historic Dist. ( t,Kteplacing like for like Pool fencing *The debris will he disposed of at: r /4 eri YA/i7)o-1-1... I-Alo1i Location of Facility I declare under penalties of perjui at the statern Is 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 o- ntio of ;I ei e and for prosecution under M.G.L.Ch.268,Section I. .... Applicant's Signature: . Date: 2-—/a''7-00 Owners Signature(or a I at) _Dote: Z —/0—202-42 Approved By.. Building Official ko desi, e) EMAIL ADD i: Zoning District: Historical District: Yes No Flood Plain Zone: - Yes - No Water Resource Protection District: Within 100 ft.of Wetlands: l i Yes No 7 Yes ..- No ' The Commonwealth of Massachusetts ., � Department of Industrial Accidents minitSIN^. 1 Congress Street, Suite 100 imp _�. Boston, MA 02114-2017 — �r,�» wwrv.nzass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): �Q Y7 A'A 4 ,7' Z->C Address: ,V P/ pw2,)l,. ei / City/State/Zip:XyjnAlitkl-, fi/ 671'7� Phone #: 7 ? II—Z6'2—1612 Are you an employer?Check the appropriate box: Type of project(required): 3._HV I am a employer with �� employees(full and/or part-time).* 7. C New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. L Remodeling any capacity.[No workers'comp.insurance required.] 9. E 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.C Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 3 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other 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.C /�� 4)e- / y-1Insusurancance Company Name: Policy#or Self-ins.Lie.4: &% civy 06 A-- /6 7 Expiration Date: /Y 2._e,2 d Job Site Address: is � i27/7 d City/State/Zip: irP a'k4�4- inii-0'26 7S Attach a copy of the workers' compefisation 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 verificatio A I do hereby c' yr de the ai and penalties of perjury that the information provided above is true and correct Signature: / 2.-- Z020 Date: /D Phone#: / 7.7 y—i i&i Z- Official ,se ly, 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#: i Commonwealth of Massachusetts Construction Supervisor Unrestricted-Buildings of Professional Licensure of any use group which contain Board of Building Regulations and Standards less than 35,000 cubic feet(991 cubic meters)of enclosed • ConstructiUn'Supervisor space. CS-103019 E Aires: 12/03/2020 JEFFREY D WHI 32 PLYMOU DTE {�,. YARMOUTH PORT MA 16TS i,,' Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Commissioner CAL i Call(617)727-3200 or visit www.mass.govldpl f Registration valid for Individual use only If found return to: '/fi. 14,/II IA.ANC",I///,/ l/•,'•,,,,41,, //, before the®)t iOnA}fairs and Business Regulation Office Of C.Onfu Orrice of IMPROVEMENT Consumer vttalrs 8 Business Regulation 1000 Washington Street -Suite 710 HOME IMPROVEMENT CONTRACTOR TYPE:Individual Boston MA 02116 , t .'I i 165058 12/16/2021 i ..__... . I. JEFFREY WHITTEMORE .z r ` it of valid out fig fe t i JEFFREY WHITTEMORE �� , 20 ROGERS RD ___ HARW ICH,MA 02645 Undersecretary