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Home My WebLink AboutBld-20-004354 Office Use Only `' ff.Y `r'- s/ Y, C Q _ 1,1 ,► y; "Amount E._ .:N Mwrr n es =_ u',,,,'n� gi,: Permit expires 180 days from -- i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: �A / /� U ASSESSOR'S INFORMATION: Map: 7 / 3 3 Parcel: 1 OWNER: iiVdf) AkrrOyAt co �s)"o( f1SNAME PRREL. # 19le ul l t/f �2 �� /�/' " ' 7'o".vd ,2 2 0 on Hc''7 ate W ►i -� CONTRACTOR: " d 6_ e q 6—3 eri NAME MAILING ADDRESS TEL.# 'Residential ❑Commercial / r ] Est.Cost of Construction$ L/e 6 J , O O Home Improvement Contractor Lic.# // 6 ` ` Construction Supervisor Lic.# 6 C 17 0 - Workman's Compensation Insurance: (check one) ❑ I am the homeowner 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 /( ( 1,4461nove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Wl Rt•Q, C.t1 DO rv1 1 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 revocatigp/of'my�license and for prosecution under M.G.L.Ch.268,Section 1. /.�/4,/ t e,� �/4/2 Applicant's Signature: ��77 Date: Owners Signature r attac cut) ,�A i / Date: S 02 /9 i /` -�' � '?OZO Approved By: —e � Date: 2 Buil.. g 0 .-1r. •. ghee 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 The Commonwealth of Massachusetts !f _W, — L Department of Industrial Accidents er =LAR 1 Congress Street, Suite 100 •—_ _•. �_ Boston, MA 02I14-2017 www.mass.gov/dia imp ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ,�J Please Print Lezibly Name (Business/Organization/Individual): /y/.0//' / 0�Ao Address: -2. O C.V /l h'/7f4- t/ City/State/Zip:AI g/lc/1i /'W, D Z GVr Phone#: g — 2 y6-3 -5/ 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. ❑New construction 2gI am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 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. 12.0 Plumbing repairs or additions 5.1=1 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.$ 1 Roof repairs 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 stare 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 penal/ties of perjury that the information provided above is true and correct. Signature: " %� " ` k r Date: z7,15 O Phone#: :5-0 K_ 2 4' 3 es'/ 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#: /', / Division of Professional Licensure Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards f.r HOME IMPROVEMENT CONTRACTOR ConstrudttiA F TYPE;Individual N. •, pt:rvisor t y Aeglatratlop Expiiation 118017• 03/03/2020 CS-001702 N Expires:09/19/2021 PHILIP R.POND JR " IL PHILIP R POND, JR ," ` 22 OLD HERITAGE W/4X HARWICH MA,,02645 = ,'. PHILIP R.POND l.-/ 22 OLD HERITAGE WY" �!2 - -' 1�i1Sti:I;lk-i'' HARWICH,MA 02645 ' ) ' Undersecretary Commissioner T • • ( r--„....., • i'