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Home My WebLink AboutBLD-23-003753 .0�.ygR -Office Use Only + I Permit# h,V c . : � 90— O �l� . H �Amount ��r MATTA M CS[�� j\Santa 1. Permit expires 180 days from -' tissue date —9th-23-•170 37S3 EXPRESS BUILDING PERMIT APPLICATIcii E-C E I V E D TOWN OF YARMOUTH Yarmouth Building Department 1 JAN 10 2023 1146 Route 28 y_ South Yarmouth, MA 02664 By: IL --V..L124:161-- (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 021 tittikkk ASSESSOR'S INFORMATION: Map: 2_2_ Parcel: 2.7 OWNER: 61e1A I L-GL(fro 6 A 2 L !'re..4 kiwi $i7, • AME PRESENT ADDRESS TEL. # CONTRACTOR: � I `� 6 C( I e,oL, W i d NAME ��ZZl i MAIL G DRESS TE .# rs Residential 0 Commercial Est.Cost of Construction$ 8 oda, " Home Improvement Contractor Lic.# 17 c 11 G Construction Supervisor Lic.# C S -Q zi6 l ?.o Workman's Compensation Insuran e: (check one) 0 I am the homeowner I am the sole proprietor ❑ 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: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 7C�/Vt0, K/re-114-'-► *The debris will be disposed of at: To( )H, 0 4 g 11Z_PVL C) _ . L ation 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 revoc ' n o y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: /--q--Z3 Owners Signature(or attachment) c...e_e . Date: Approved By: Date: 1//6/94 3 Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: 0 Yes X No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes C Io 0 Yes Cff4 No a _ .. The Commonwealth of Massachusetts Department of Industrial Accidents 'e 1 Congress Street, Suite 100 _t�= Boston, MA 02114-2017 5 www.mass.gov/dia NIPWorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): c f2 t k �,y tv-l- L i .0 Address:,,6ct SI Sties > - City/State/Zip: ,/4 J OIA, 6 673 Phone #: -3 a 1.2\3 Are you an employer?Check the appropriate box: Type of project (required): 1.0 I am a employer with employees(full and/or part-time).* 7. E New construction 2,I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. emohti0ri ❑ y [No workers'comp. insurance required.] 10 E 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 11.0 Electrical repairs or additions proprietors with no employees. - 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.E 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#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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: 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 and r the pains and penalties of perjury that the information provided above is true'and correct. Signature: Date: / ?-?3 Phone#: S) 6 9 ZZf3y Z. 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#: 1/8/23,8:51 AM iMQ5900,jpg Owner Authorization ,t4,-M4/4 as owner ot the slatted property hereby authorize 1E105/9,4y Af40/160116 T:act on my behalf in matters relating to work authorized by this building permit application. Signed under the pains and penalties of perjury. Opvt,nt()e Signature of Owner D e *Please sign, scan and upload this form to your permit. • Commonwealth ot Massachusetts f Division of Occupational Licensure Board of Building Regulations and Standards Cons . ,* ill tort S - visor 4 f CS-046420 15*pires. 11/14/2024 EDWARD 1- 8;TAFF4t* 269D SOUTH/SEA AVE W YARNIOUM t 3 c 31R, 0111.111/#441)*At**04.***. # LJ Office of Consumer Affairs&Business Regulator HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. if found return to: RegistratiOn Expiration Office of Consumer Affairs and Business Regulation 175128 04/24/2023 1000 Washington Street -Suite 710 LEWIS BAY MANAGEMENT,LLC. Boston,MA 02118 EDWARD STAFFORD 64 HEflITAGE DR Not vali without W.YARMOUTH,MA 02673 Undersecretary