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Home My WebLink AboutBLD-23-001422 aa,11A gJz>>53Z- Office Use Only O 44% Permit# Cf 9 0C! O '�+ Amount fO w `,�,"`""•••fit'"-r, . Permit expires 180 days from --:'l:.:::' issue date 60 — 3 - (w22 EXPRESS BUILDING PERMIT APPLICA TOWN OF YARMOUTH RFC °` . $ VED Yarmouth Building Department , T 1146 Route 28 i I SEP 16 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 our T CONSTRUCTION ADDRESS: ) 7 TO 0 D 62-dr ASSESSOR'S INFORMATION: Map: Parcel: OWNER: L 7 `OO 2 RA &Jo wt)6, -e,_ Cd T C f A) ) /tiv ) r 2& A/a/ P 6- NAME 2_Gi G("1.,0-. . 5 7— 2 PRESENT ADDRESS e;�� —7^j TEL. # / '1[.1 117 C) CONTRACTOR: LU ((`Oo/i r PO 31 AG-44 ? ,V' /nd, A4- 02 1(/ $O �G17 9.7? NAME MAILING ADDRESS � TEL.# esidential 0 Commercial Est.Cost of Construction$ /Z/e AO Home Improvement Contractor Lic.# " I (Y ' Construction Supervisor Lie.# C S CO 0 —N Workman's Compensation Insurance: (i4ick one) 0 I am the homeowner el am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy WORK TO BE PERFORMED Tent D Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 5' Replacement windows:# Replacement doors: # Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation n nOld Kings Highway/Historic Dist. tJ Replacing like for like i Pool encing n 65-d 64 e�_9/1 ;r 1'h.) Rtf 4/ VA-//1 *The debris will be disposed of at. /1 /(if','Q ti-6 ---- ,..)d'In e Location of Facility I declare under penalties of perjury that the statements ein 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 lice . : . for prosecution under M.G.L.Ch.268,Section 1. /Applicant's Signature: 7 " Date: C/(: ` 1 2— A. 7//sJ2zOwners Signature(or attachment) i IDate: iri Approved By: ��../ Date: �1°. Building Official(or design MAIL ADDRESS: �/ �!J f� --0 /'f) , �y--l—` Zoning District: �I v �J uc �'L 7 Historical District: Yes No Flood Plain Zone: I- Yes r No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No . The Commonwealth of Massachusetts ==.=+ 1=11 Department of Industrial Accidents =sc/11_ I Congress Street, Suite 100 �; � Boston, MA 02114-2017 `, www.mass,gov/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): /9irk/ v/t/cI Address: 12d U/ (t 6f Z UZS5/ City/State/Zip: ,��✓h ''J 1� v� ket Phone#: V ' / 2 - 90 j Are you an employer?Check the appropriate box: Type of project(required): I.❑I a s employer with employees(full and/or part-time).* 7. 0New construction 2 am a sole proprietor or partnership and have no employees working for me in 8. Ej Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself. [No workers'comp.insurance required.]t 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 0 Building addition 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 5.0I 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 / 6.0We are a corporation and its officers have exercised their right of exemption per Mal,c. 14.._ . Cher L G 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. tContractors 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 n e pait/enalties of perjury that the information provided above is true/and correct. Signature: Date: C�/ / L- 2, 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#: Commonwealth of Massachusetts Division of Professional Lrcensure r ulations and Standards Board of BuiVdin9 Rft ConstralL't rvisar xpires:0110212023 CS-060795 EVAN K POUNDER THE COMMONWEALTH OF MASSACHUSETTS Po Box saz FALMOUTH MA 02li47 1' ' � , \ Office of Consumer Affairs and Business Regulation 3�,-� 1000 Washington Street - Suite 710 , Boston, Massachusetts 02118 Commissioner ,!, �"` Home Improvement Contractor Registration Type Individual EVAN POUNDER Registration 170163 PO BOX 642 Expiration 12/05/2023 FALMOUTH, MA 02541 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Individual Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 170163 12/05/2023 Boston.MA 02118 .VAN POUNDER K,..".,) EVAN POUNDER 143 ACAPESKET RD tia_—,'; -r.G(Osd EAST FM MOUTH MA 02536