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Home My WebLink AboutBld-23-002448 OYII R t X Pl i k 1 0 ZE— RECEIVED Office Use Only k: . `FO Permit# OH 'I• y- NOV 02 2022 ;Amount' D di Al' £St 4a.....Iu^,er'd _ _ ...• _ _ :i . '' s from BUILDING DEPARTMENT jissue^date BY---- C - EXPRESS BUILDING PERMIT APPLICAT e . J TOWN OF YARMOUTH Yarmouth Building Department 6 L0`a-3 - DO al-Nq 8- 1 146 Route 28 South Yarmouth, MA 02664 t. (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 9 (J 5C)( c'( \ , 0 a g o--- ASSESSOR'S INFORMATION: j� Wilt ,/Parcel: �/ / / p OWNER: PO4VU ta��/_2✓ 9- L �5t/1 tJar 1 ur/y1d� /// `S 60-t I- 3 " NAME ,/ PRESENT D SS i YeAibliteil/ TEL. # CONTRACTOR: .(� ��r() uh 1 i/ elofId '� 7r/ yj/-3 .JjOI/ NAME MAILING ADDRESS TEL.# *Residential 0 Commercial Est. Cost of Construction$ 24 d 06 Home Improvement Contractor Lic.# ! I I16 7 1 Construction Supervisor Lic.# Lf—D;ya v. Workman's Compensation Insurance: (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 tardant Certificate attached?) Wood Stove 1c,a, i',! slyde fix ;wt -erg 1 i / ng: #of Squares Replacement windows: # Replacement doors: # //�.)47 /dPottARI✓dai f5 f%b4 f- Suin6 roo✓� Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old King Highway/Historic Dist. ),Replacing like for like Pool fencing L \Oa fie-I rice_ 177J- *The debris will be disposed of at: ��otit ft4i'1 'f ��/�� 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 r vocation f y lice and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: --- Date: /V O V a. 26 2 Owners Signa re(or a chment) Date: Approved By: Date: /1/7/2 1- Building Offici r desi" EMAIL ADDRESS: Zoning District: Historical District: 0 Yes C No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No r -6t The Commonwealth of Massachusetts A Department of Industrial Accidents 1 Congress Street, Suite 100 4-116 Boston, MA 02114-2017 —5.•` www.mass• ov/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): G i ` G/' it 77 Address: 1 / utilJ d t /�I vl City/State/Zip: \hi/ 104 ttF r Phone #: .7P/ 9{) Are you an employer?Check the appropriate box: Type of project (required): 1.O I am a employer with employees(full and/or part-time).* 7. New construction 2."t'I am a sole proprietor or partnership and have no employees working for me in 8. 2 Remodeling any capacity. [No workers'comp. insurance required.] 9. _ Demolition 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.] 10 ^ Building addition 4.11 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 5.11 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[I]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.El Other 152,§I(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 $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: � '"" `� / - Date: ,: a� Phone#: 7 / ''l 5 ( Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts tir Division of Occupational Licensure Board of Building Re ulations and Standards • Cons�tiorit$ visor tt CS-059262 ,r f! itplres: 11/09/2023 SCOTT J HOORIGAN Iwl � 44 CAMELOTiRD L. • YARMOUTH'IdpRT MA 02675 0 l�• s.tiw „ti 3 '40IJ,Vdil'J�• Commissioner Clla a K. b a, • • • • ginv zo�u eod�g/,/,a.i.iezdei jean Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 184079 11/04/2022 SCOTT HORRIGAN • SCOT-HORRIGAN 44 CAMELOT RDA(2 - YARMOUTHPORT,MA 02675 Undersecretary 10