HomeMy WebLinkAboutbld-20-003765 • mii9F'6_C 774
c
0
+!'I• . H lAmount
TT`MA - M CS 0.1,
ar„"""""s !Permit 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: Sc 7 )3.G4 sAnd d L- 4r✓n olik (14, 0 Z.G 7.3
ASSESSOR'S INFORMATION: Lv -1 e Sq, 1 4 $he — /u p 04 f I
Map: Parcel:
OWNER: 17) .-, o, 1 -
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Gvw 1c. /Zqd &nn‘� 4+l . C 'Jos10eN 014+,al Zk f- I7-567-bcco
NAME MAILING ADDRESS TEL.#
❑Residential )(Commercial Est.Cost of Construction$ 3 S vuo.ocr /bk
Home Improvement Contractor Lic.# Construction Supervisor Lic.# CS - I11 21'3
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor X I have Worker's Compensation Insurance
Insurance Company Name: &ra,.J /�U/vk/ Srrore[r aired y. Worker's Comp.Policy# /9Zz
•
WORK TO BE PERFORMED •
Tent Duration 60d.c y S (Fire Retardant Certificate attached?) oo tove
Siding: #of Squares Replacement windows:# 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: SAl"W;GL )Ix..ts icG/ .44 ail 500►'1 - 13o C.SAvttl wart i /4I4, OZ 53 7
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 revocc iioo of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Sig atur. .� U '1 Date: /••• 7 OLl�
Owners Signa re(or a :chment Date: 20
~ / •J• 2�1
Approved By: Date:
Building Off ee EMAIL ADDRESS:
•
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
The Commonwealth of Massachusetts
'= Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston, M.A 02114-2017
�5.• www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 6 (Ito _In c
Address: /ZOO t nr�;nl fit, S,� 4-7 !3osiori a Z I Zj-
City/State/Zip: L' 3o f/a fr, 1 1�/ pZ/?1- Phone #: /- 6/7- - 7- 6 o oe
Are you an employer?Check the appropriate box: Type of project (required):
1.X I am a employer with 75 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.]
3. I am a homeowner doing.all work myself. 9. ® Demolition
y [No workers'comp. insurance required.]'
l0 E Building addition
4.a 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
3.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs
These sub-contractors have employees and have workers'comp. insurance.t
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: 4rro,,,_, 4/,,,1/4/ 1 s�ny n r C ��.►�.,
Py
Policy#or Self-ins. Lic. #: /-47/41 /41gA Expiration Date: I/ t i toL
Job Site Address: .5-2)/ .fives( Js/a,4,(1 1 t{ City/State/Zip: /J, yu-ntov/k MO/ Ot673
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: liar// Date: /- 7- ZOZO
Phone#: /- 7;f 7 - 04127
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#:
(kir e cS&k1 S �e-d
:..oF.YRR TOWN OF YARMOUTH
$
o• BUILDING DEPARTMENT
:N ;:Ti."-Es 4'. 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 261
BUILDING DEPARTMENT
TOTAL DEMOLITION SIGN-OFF FORM
State Building Code (780 CMR) Chapter 33, Section 3303.6-Service Connections
"Before a building or structure is demolished or removed, the owner or agent shall notify all
utilities having service connections within the structure, such as water, electric, gas sewer and
other connections. A permit to demolish or remove a building or structure shall not be issued
until a release is obtained from the utilities, stating that their respective service connections and
appurtenant equipment, such as meter and regulators, have been removed or sealed and plugged
in a safe manner."
"All debris shall be disposed of in accordance with 780CMR 111.5."
Building or Structure Location: 3-enelhak gd Map: Lot:
Owner's Name: T of Ye Al(-L Address: Phone:
Contractor's Name: 6vw.�,c� Address: / ein�►�wng- Phone: /-(,l7- %7 -Ccrz
Eversource: Date: F �ww33 nt�,ot'r sr
By:
Title:
National Grid: Date:
By:
Title:
Water Dept.: Date:
By:
Title: S
Cc ç
d
Board of Health: Date: 1
By:
Title:
Condition:
Fire Dept.: Date:
By:
Title:
Historic Commission: Date:
By:
Title:
Conservation: Date:
By:
Comcast: Date:
3/15