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Home My WebLink AboutBld-20-004093 .01 YRR orrice use only O Permit# O , - • .....1 Amount H MATTACM ESE �,4t......00 1,0 PPermit expires I 0 days from BL v V�— 't 'M 3 issue date �- EXPRESS BUILDING PERMIT APPLICAT # C E IVE- �--- TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 .4 BUILDING DEPARTMENT South Yarmouth, MA 02664 By ,_._ (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: A 65 Sw� .• S 1\Ove Dr. So mtdd,E 1De hc\l ?ethw - ASSESSOR'S INFORMATION: Map: 1 Parcel: OWNER: t Own c� Mc � Left-rx>TAN I 0-IA RT. a£) NAME�� __� PRESENT ADDRESS TEL, # nn CONTRACTOR: nD�T11 LLt.) U LX ao CR �tr s I n. Sirciti,,1GIN (f f1 0,461 7?Li-a l a - >l og NAME MAILING ADDRESS TEL.# ❑Residential CiYCommercial Est. Cost of Construction$ aVO-cip Home Improvement Contractor Lic.# Construction Supervisor Lic.# C. S - Os-a 87.g- Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor 2 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:# /U Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( 4eplacing like for like Pool fencing *The debris will be disposed of at: 6,06 Fi:nPS1- R A. ?ictr(11CAAt,k fn i. 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 m license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Si.,, ature: A r. AidliP .411k ` Date: —Q41 —p 7 C Owners Si_nature(or a : 1 -' '/ 1 . Date: /. ' , ,22.•X Approved By: S�� Date: Build' '1STf(or.= gne' EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes No Flood Plain Zone: 2 Yes , No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 2 No 2 Yes 2 No The Commonwealth of Massachusetts lr / Department of Industrial Accidents 1 Congress Street, Suite 100 } Boston, MA 02114-2017 s..�'4.7 www.mass.gov/dia IMP Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LegibIv Name (Business/Organization/Individual): 7j;) d.' Uj4{`Iy\c th Address: //4/6 aR4trulki City/State/Zip: `1't rYNut -k y6. Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. 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 10 ^ 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.[ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.E1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp. insurance. 14.[J]Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. refkce vs•Aciety� Cie) 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. 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: & tik S oce t City/State/Zip: ClarYncrt,441 IA . 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: �' �G Date: / — -gCyard 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#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Conan u a (visor CS-052875 ;{' ,* f5L,pires:03/23/2021 ROBERT W ' , PO BOX 1886r ��1 SANDWICH Commiissioner