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Home My WebLink AboutBld-20-004651 ,,-ai'•Ytg,R-. Office Use Only • .k.. �7 Permit# O l H 'Amount SD •. MATTA . 3 :�+�,'`" �•' �"�` p _ / _ I 3 Permit expires 180 days from Bl�) 'v/'1``� issue date EXPRESS BUILDING PERMIT APPLICA I Ql C E f E C� TOWN OF YARMOUTH -----1 Yarmouth Building Department - ii E 1146 Route 28 g South Yarmouth, MA 02664 B u igi �� E- ,, N I (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: , 3 (-0 LS_✓t iAA f R D U _y - ASSESSOR'S INFORMATION: I Map 1 � fl ( / O� c, Parcel:03 Q.(o0 �C=�� l OWNER: ' _ ( (,''4 j I 3 Od• �:C.C,GOTy. 0 C -`AV 08 -I (P i T �D C (707/ fectonaLlif RESENT ADDRESS TEL. # `CONTRACTOR: all ) d'j Pik - 8' 7 %'"-/y7:-..r- NAME MAILING ADDRESS TEL.# Gltesidential 0 Commercial Est.Cost of Construction$ �OJ d D 0 Home Improvement Contractor Lic.# /v "v 011/ Construction Supervisor Lic.# 10 a Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation J Insurance / �� n "3 Insurance Company Name:/�f �� / Worker's Comp.Policy# �� , (� v8F 4697 WORK TO BE PERFORMED ,—(5c)1; Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares IRe/placement windows:# Replacement doors: # Roofing: #of Squares /4 (X)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing ��par/' CI 1'i -Q � F'�0 I ivi - *The debris will be disposed of at: d 7.J 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 o revocation f my licen and for prosecution and .G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachm t) Date: 0)--- U� c)-'V/0 Approved By: .......) i Date: )s% t a q "4& Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: Yes I No Flood Plain Zone: C Yes ,I No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No I Yes P No The Commonwealth of Massachusetts -, 1— / Department of Industrial Accidents _:i` 1 Congress Street,Suite 100 14 Boston, MA 02114-2017 '"Z:r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual): V a V haw Rew Q, ud Address: / City/State/Zip: �P 1aO 2 'ij ° ' 7 Phone#: 3 r/� —�� —S Are you an employer?Cheek the appropriate box: Type of project(required): 1.ig I am a employer with l employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work t 9. ❑Demolition ❑ myself[No workers'comp.insurance required.] 4.0I am a homeowner and will be hiring contractors to conduct all work on my p P�'.Iw�11 ro 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors th 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.®Roof repirsr These sub-contractors have employees and have workers'camp.insurance.$ f4e,6.❑We are a corporation and its officers have exercised their ri t of exem14.❑OtherC Y 4 �-c r e 152,§I(4),and we have no .insurance exemption per MGL c. employees.[No workers'comp.iasuramcx 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. / _ S/U 7-CJdl Insurance Company Name: L.i �1 r4 , /- Policy#or Self-ins.Lie.#: jJ3/5 3 0 Q2 Expiration Date: /2 - Q ? —2 d Job Site Address: tcA City/State/Zip: c raV - /10 17 2 6 Y. 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 perju the information provided above Ls true and correct. Signature: Date: 2- D Phone#: j 0 9Y--7 f 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 CIerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Fewi/noneeeaarA,Az,i4aWaJeti<s• Office of Consumer Affairs&Business R•gulatIon HOME IMPROYMENT CONTRACTOR T •Individual RL Elgirat121107/01/2020 VAUGHAN C. Tf, VAUGHAN C R 38 THORWALD D .‘' „)' • S.DENNIS,MA 02660 Undersecretary Commonwealth of Massachusetts 11) Division of Professional Licensure. Board of Building Regulations and Standards Cons 4 res: 05/27/2020 CS-000949 up,rvuispoir VAUGHAN C RENAUD,I,'"1 C'• mokA, 38 THORWALkOR • gr SOUTH DENNIS041A 02880 \ Commissioner • •