The URL can be used to link to this page

Home My WebLink AboutBLD-23-002516 -- q `Office Use Only - r o,-,r4 4., e G off— _{y ,' 4 C ]Permit# ez. 3 Z Ou 1 // /` �-' AAmount 90.64 C MATTAC/I fSE IPermit expires 180 days from issue date l3Lh- Z3-6D�5) ' EXPRESS BUILDING PERMIT APPLICATI t E C E V E TOWN OF YARMOUTH D Yarmouth Building Department H0v072u22] 1146 Route 28 South Yarmouth, MA 02664 —__—__ (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT �� / BY CONSTRUCTION ADDRESS: 5 7 / / h�� « Gi �, J` Cf cjv[, ,, L ASSESSOR'S INFORMATION: Map: I Parcel: OWNER: 6 "5 /1✓4,0/-4.) -5-6 P//7[_ C face-- n d 5b -3 ry a yy NAME '/ [ PRESENT ADDRESS TEL. # CONTRACTOR: Pet c./U 19UiJmjo/) ` 1/ 0 S),/2- �/ fti '0,44 6/7SYd* NAME MAILING ADDRESS / TEL.# / esidential ❑Commercial Est.Cost of Construction$..2--0 �/.'sr0 a /Home Improvement Contractor Lic.# /S� C/, s� Construction Supervisor Lic.# � OC4E.. Y1.7 Workman's Compensation Insurance: (c one) iiC 6 4 4- 0 I am the homeowner am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED np o 'c/, -`f. 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 *The debris will be disposed of at: L ? ,f✓t.2a' )/G/'i111 /15Q L_'i# ( .. 0-- 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 I. Applicant's Signature: Date: /ti 6v /, 262 Z Owners Signature(or attachment) Date: / Approved By: Date: ! � — Building Offfici r de ' ee) EMAIL ADD . Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts -*-a- • 'I _+:, � Department of Industrial Accidents de�,l- 1 Congress Street, Suite 100 =_r`= Boston, MA 02114-2017 5.•`''y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): 12 'ci /9,. /tj 7' )9 I-7 Address: /Oa ,S)9r'1,.."66_, City/State/Zip: /d 62ly Phone #: C/7--SIS3jY/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am Toyer with employees(full and/or part-time).* 7. ❑ New construction 2 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 Ll 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.E 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.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#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 under the pains and penalties of perjury that the information provided above is true'and correct. Signature: tom' ' Date: Phone#: 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 and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration N tCD Type: Individual N Registration: 115696 N o , DAVID H.ABROMSON Expiration: 04/23/2023 m o 100 SPRUCE ST. �, (a FOXBORO,MA 02035 rr ' ° N CL J C .° , vistoA 0� . m c p ... $r �n l`- 2 2 Update Address and Return Card. E = :a ; li,�--- i �, SCA 1 0 20M-05n7 d O o._ ?_�' C j ./j/�-� /---- _. C---- -- -///-- --. G / ---- - _ e Office of Consumer Affairs&Business Regulation o x C � �1 \, i. HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only E ;N al 0Ul V a TYPE:Individual before the expiration date. If found return to: o o Q 5 o • p Registration Expiration Office of Consumer Affairs and Business Regulation U o? i C a O o 115696 04/23/2023 1000 Washington Street -Suite 710 o n N m 1. c. �Ctl Boston,MA 02118 m o G 8 o i rJAVID H.ABROMSONu.a, �� ci v) co „I U - DAVID H.ABROMSON 100 SPRUCE ST. r(u"`4l 4('''G(`'t.L. , FOXBORO,MA 02035 Not valid without signature Undersecretary • ,