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Bld-20-005008 ffice Use Only ;'p?C'YRR 0 . 'l /t• . H` I Amount ( t°"0"'�0" v 'Permit expires 180 days from - I -'•' i issue date EXPRESS BUILDING PERMIT APPLICATION '_c 1";�a,� - TOWN OF YARMOUTH Yarmouth Building Department i ';;k , , ) ', 1146 Route 28 ` un South Yarmouth, MA 02664 1 -, _J (508) 398-2231 Ext. 1261 ,� '� CONSTRUCTION ADDRESS: iJ Ctr 1-)-. qr p N W it. L la../ /Q.illeii0LIP/ ASSESSOR'S INFORMATION: '��1 Map: nn Parcel: t 1 OWNER: 6 I L) 610 i 1�I V Y ;%,(�!t, k n T L # g3 4, o g Tl� N SENT AD/ SS TEL. # CONTRACTOR: D 1r,-A/,- N &J u1.1�� ��? p( 11�'!d 7""A 20 '7)''�._?jS'?j,_6(f C31 L- NAME MAILIN ADDRESS . TEL.# esidential ❑Commercial Est. Cost of Construction$ ?tic>L7 e J Home Improvement Contractor Lic.# /L( if I/ Construction Supervisor Lic.# 6j''We 7_2 Workman's Compensation Insurance: (check one) ❑ I am the homeowner (VI am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: .j 0 L j ,Qv0.0 Worker's Comp.Policy# CCV 4(.S _ I '� WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 2. Replacement windows: # 10 Replacement doors: # 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: .1 41 k.t,)i . 1 j g-11 �'r'- Location of Facility I declare under penalties of perjury that the statements herein contained are true correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial ocation of my lic se prosecut. un i .G.L.Ch.268,Section 1. Applicant's Signature: - Date: 3 /0 2_;41`) Owners Signature(or attachment) /' `;s ) Date: 3// }_ 0 Approved By: ...Ad:, � Date: I s O r Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 2 No -q.. The Commonwealth of Massachusetts / i, il Department of Industrial Accidents I Congress Street, Suite 100 . Boston, MA 02114-2017 '4 0,�,�,5�•"' 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): D p. Cr Cc e'.S r VIC_ fO '_- _ Address: 9? f)4/ ( ,,/x, 20 lvi.... City/State/Zip: I4i w/6 .,, 6 7_6(5hone #: 7)`i�' — s3..- 6,e Z .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.D 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.❑Plumbing repairs or additions d.❑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.: 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#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. Insurance Company Name: ✓V 0 E.61-4 U �.) Policy# or Self-ins. Lic. #: 060 t./.6 cz..4 Expiration Date: °�(..— 2.0 Job Site Address: IZ co S1i 1' j 0 , L Th City/State/Zip: U-3 J4�:/Lto .1-r LI Attach a copy of the workers'compens ion policy declaration page(showing the policy numbef 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 cert. un er the pains an Ries of p ju at the information provided above is true and correct. Signature: 6 illDate: 3 /1,./Z 0 Phone#: 77# 275 --(o,'f 92 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#: Office of Consumer Affairs &Business Regulation- Mass.Gov Page 2 of 2 Zip code Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund history. The list is current as of Sunday, March 8,2020. Search Results RegistrantNameRESPONSIBLIREGISTRATII'DRESS EXPIRATIMATU INDIVIDUAL NUMBER DATE DAVID H. GOULD GOULD, DAVID 121411 98 OLD 04/16/2021 Current CHATHAM RD N. HARWICH, MA 02645 Site Policies Contact Us ©2018 Commonwealth of Massachusetts. Mass.Gov© is a registered service mark of the Commonwealth of Massachusetts. https://services.oca.state.ma.us/hic/licenseelist.aspx 3/10/2020 Details Page 1 of 1 Licensee Details Demographic Information cull Name: DAVID H GOULD wner Name: License Address Information City: HARWICH State: MA Zipcode: 02645 Country: United States License Information License No: CS-076280 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 5/10/2019 Issue Date: 4/7/2011 Expiration Date: 4/7/2021 License Status: Active Today's Date: 3/10/2020 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents https://madpl.mylicense.com/Verification/Details.aspx?result=02aa9852-8997-4743-bf66-... 3/10/2020