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HomeMy WebLinkAboutBld-20-005015 - Off,.yRR � ,>� � � � � � 'Office Use Only s • _ F - S ~ � C 4 {PenG #�/ 3 O - . H' !Amount •• MATTA M ESE. � i ? D ' i L l q yy AkE e I Permit expires 180 days from 61) issue date t Asa , EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ` /C-- . '' 1/4 -k3 r A `= L� '�/ /",•` ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 3 r i o.... // i YV e0,- t' Cb-N.-- .4' L . i ✓1,/�C� Gt'�G; r,J_ �(�. `/.-:1A A�iuf�T NAME J,�PRESENT ADDRESS TEL. # / / � , , � CONTRACTOR: ,4 't' �� (�-c CA-t.('A'''''�e� (i ��r t- S" 6. 0..1 , 3 ) 95 9_' 1\kv1E ,5 MAILING ADDRESS TEL.# V Residential ❑Commercial Est. Cost of Construction$ l`c' S(x e—r• ' - ----' �C...)Home Improvement Contractor Lic.# I c✓37 cr../ Construction Supervisor Lic.# l© /0 7 • Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am/the sole proprietor J I have Worker's Compensation Insurance Insurance Company Name: A '"`f- G Worker's Comp.Policy# j`v( • 500,50/'058 fla .1 CA 7 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares rc/ (54()Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing ut.42,14.4/.. , *The debris will be disposed of at: Loca 'on 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 my license and for prosecution under M.G.L.Ch.268,Section 1. — Applicant's Signature:_ ..i � Date: 693 — ° -Jo Owners Signature or a ach __ 1 Date: � - .zff Approved By: � L .�1 Date: 5. /) 27 Br. T"ding Offici. or desig R� i L ADDRESS: Zoning District: Historical District: ❑ Yes = No Flood Plain Zone: ❑ Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No El Yes _ No The Commonwealth of Massachusetts v Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 „ s.•`''y www.mass.go v/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): Address: Zc ,, '�— City/State/Zip: - ,tVv ' Phone : 5 cic 3 f5 q 1 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.XI am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. 9. - Demolition y [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.D Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Ej Roof repairs These 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.El Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box f 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: / (rt. Policy 4 or Self-ins. Lic. #: (, /CC .. 00$° I& L 7, C'( r/ 4 Expiration Date: y- 3 .. Jo Job Site Address: Z ANA �' 16-- i b. En 4'2 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 penalties of perjury that the information provided above is true and correct. Signature: '"'— Date: 1 Phone#: 5o,J9 02 3 7 g 5 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 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#: (/vfiliilL i!li�reLuiL u�✓vl%/G7JCGf/LCCJPLLJ DivisionBit of ProfessionalReonand sure Stan Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Constrtutt1.61Y iSprrvisor TYPE:Corporation ./1 Reaistr Lion Expiration C; .44107 6cpires:08/25/2021 153792 01/07/2021 CARLOS H FIGUEI' • 114 1 C&F REMODELING . 20 CAPTAIN I9OYES • •1 } + . SOUTH YARMOUTH S4 r �" C � kt- CARLOS H.FIGUERROA 'Koss .:1 10A1 ��' �� " ' 20 CAPTAIN NOYES RD. 0 S.YARMOUTH,MA 02604 Undersecretary Commissioner • • .i. •