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Home My WebLink AboutBld-20-004352 . R..• .01'.YR lb jvu e use vniyEY[hh1Y AO P ca H !Amount u I ` MATTACt1 f5[ �,`*Ona.�'' :d 1Permit expires 180 days from 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: i 7t Ai- elk- Li,. ArM0a714 ASSESSOR'S INFORMATION: �l 1 Map: / Parcel: 0102.4 n // t- OWNER: 5/fT i P��twl; 3 A//s e) On1M4( i) ltd." /14 c�oir-cr/3 -- ticiLt NAME PRESENT ADDRESS TEL. # CONTRACTOR: rd ides') 47v /S t3ap' *c S-f- 4,r400 O,Z110 6/7`1,35 S O3 t 1 NAME MAILING ADDRESS TEL.# ❑Residential 2/Commercial Est.Cost of Construction$ .S194°-go Home Improvement Contractor Lic.# / 7( / 9 Construction Supervisor Lic.# /071?/ Workman's Compensation Insurance: (check one) I I am the homeowner ❑ I am the sole proprietor E I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED 5,e ili Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove drtAA vk Siding: #of Squares Replacement windows: # Replacement doors: # A ir. '"/,etc 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: S F " 15( o $ l ieitThi-oF Location of Facility '-81 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 tha any er(Y will be just cause for denial or revocation of my licens- d for prosecution under M.G.L.Ch.268,Section 1. r•,1111111110 ii Applicant's Shmatur • . Date: d 2/iYz/2, o Ai Owners Signa IIIIIIIII1 ont) alriler Date: �I,�6'7 prf,2 Approved By: di~� Date: 172/1 ,7,L1'/� Building Official(or:- ...,-i i1 EMAIL ADDRESS: / / Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No D Yes _ No ...+r '— The Commonwealth of Massachusetts 1� r Department of Industrial Accidents I 1 Congress Street, Suite 100 Boston, MA 02114-2017 14.„r•`' 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): £f4 8✓ia 7 I te/N Address: S , City/State/Zip: T...^,,,;ch., P1c„h,..) /410206 Phone 4: 4/7- 113S—O 3/ - 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. E New construction 2.—I am a sole proprietor or partnership and have no employees working for me in 8. remodeling any capacity. [No workers'comp. insurance required.] 9. — Demolition 3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 4.E I am a homeowner and will be hiring contractors to conduct all work on my property. 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. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E ROOF repairs T e sub-contractors have employees and have workers'comp. insurance.: 6. 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 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: 045afbmtv Policy# or Self-ins. Lic. 4: Expiration Date: Job Site Address: / 7C R4. 2,if City/State/Zip: W. ya+,Mo..t ,4'4 .,- 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: 11444( 1 ./ Date: .Z 7 ,2Dyd Phone#: 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 : 17) Division of Professional Licensure Board of Building Regulations and Standards Co nstruL•ttilliiSpgrvisor CS-107281 Expires':09/29t2021 EDWARD HDNEYCU1+,4, 15 BARBARA`ST JAMAICA PLAIJd MA 02130 ` ► 1O/Sw,I Commissioner t