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Home My WebLink AboutBLD-23-002511• ,Y 1 k L# l l ! d /Z (mice ice Use Only • O t i Permit# (%F4 0 q r, O . It4u, r . H Amount 50• l!(/ rd Ns.),,4,,°�°°��'"q`� i Permit expires 180 days from {issue date t 0-a 3-6002 50 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 NOV 0 7 2022 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: a C jCF h� V e1 i t \/a rBUll'DIN DEPARTMENT ASSESSOR'S INFORMATION: Map: Parcel: Gf- 7 7 S-- 32-i " Ct OWNER: kJ Kit 6 4 7<C2 h /- C L /t/ NAMEJoe King PRESENT ADDRESS TEL. # CONTRACTOR: 36 CheckerberryNvO�Liane �g NAME West Yarmouth, Mi b ?3D DRESS TEL.# residential e4 Q8-775-6448 Est. Cost of Construction$ - Home Improvement Contractor Lic.# )5 O f Construction Supervisor Lic.# C s.j ts... c2 c c ( We Workman's Compensation Insurance: (check one) 0 I am the homeowner ptl 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: # t 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: Ya r µc.o urk S'F-e ro.h. 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 1 ( ' Z 2.--- Owners Signature(or attachment) Date: p `Approved By: Date: • j/ 9 � Building 0 (or ignee EMAIL AD S: Zoning District: Historical District: 0 Yes 2 No Flood Plain Zone: 0 Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes` No . • ` s� `'I Vit110 The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ..5.•,$" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Jeo King Please Print Legibly Name (Business/Organization/Individual): 36 Checkerberry Lane West Yarmouth, MA 02673 Address: �-krone; 508-775-6448 City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): i.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.gLam a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑ Demolition 10 ❑ Building addition 4.0I 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 5.❑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.: 14.(XOther Lai Kiev 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. am 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-contactors 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. m: 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone g: 5-0 77 (v 4tc.f Official use only. Do not write in this area, to be completed by city or town offcial. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 4: I j . THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington StrtME Suite 710 Boston, Massachus8#s=02118 Home Im•ro z I,- tit.L.; .,.,.....=r a istration is ".inOIN if ,*". "* 4 • 4 . - Type: Individual egistration: 150889 JOSEPH E. KING « " Expiration: 05/04/2024 36 CHECKERBERRY LN. WEST YARMOUTH, MA 02673 ....... '" \\,. '' I- Commonwealth of Ma 0,,e iv Division of Occupational Licensure mot, ( Board of Building Regulations and Standards I IIi; Update Address and Return Card. ConstructioWSupe r Specialty CSSL-099166 z ,* „ icpires:01/24/2024 JOSEPH E K.OG THE COMMONWEALTH OF MASSACHUSETTS 36 CHECKE E-,-+ Office of Consumer Affairs 8E Business Regulation Registration valid for individual use only before the WEST YARM4UTH • i HOME IMPROVE expiration C A�eNt CONTRACTOR p tion date. If found return to: �? �� TYPExiv"ldual Office of Consumer Affairs and Business Regulation bfr ftealstration Expiration 1000 Washington Street -Suite 710 ghlldd7�� WP- 150889 05/0442024 Boston,MA 02118 • DSEPc4 E.KING 14. Commissioner K. bra „, 1 ,,,,_:_1„- DSEPH E.KING '. =-- z f 3 CHECKERBERRY LN ^, '' tea,j�,4- /EST YARMOUTH,MA 0� N� �;�u-,.11;�..`4'�$v" �I�L..�IEJ