HomeMy WebLinkAboutBLD-23-005935 •YRR C et, lid '4 J J 33 ;Office Use Only
.. is ! ' RECE1 �d' ED permit# aii`%2
H% 1' �P 'Amount Se,Z
C3E 2 5 2023
""`�`�p�Jd Permit expires 180 days from
v� issue date
BUILDING DEPAf4
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: / J h RE D L_A ME: _Y/9 R/ G)DH P6 R 7 I1 A O 7 5
ASSESSOR'S INFORMATION:
rr /� Map: y� �7 Parcel:r
OWNER: rqL /CF PAIN E 1'J ,1-AREo Li 1-6 S-37i5` /d?
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: C/i®CIS i A//V%' as M 1Ff4uOOb f,u s,Y,aRr J i-14 4/7 g a7 Sal z-1
NAME MAILING ADDRESS TEL.#
WResidential ❑Commercial I Est. Cost of Construction$4 a)
(,� f 2
Home Improvement Contractor Lic.# j 39 p9 3 Construction Supervisor Lic.# 05 it alb `a`l2,_
Workman's Compensation Insurance: (check one)
U I am the homeowner 4 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 i ( )Remove existing* (max. 2 layers) Insulation
in
V Old ings Highway/Historic Dist. ( V{Replacing like for like Pool fencing
o\ - .4M4 l\1tt f l\lu C uI Ail 1.) 51z-te q-// -(a3
*The debris will be disposed of at: t,>M Q S i-I-1
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 revocation m�se and for prosecution under M.G.L.Ch.268,Section 1. f
Applicant's Signature: � JJ Date: L/ - .PS- a6 023
Owners Signature(or attachment) /��.t�..n,�. / , / Date: - ��j/�,'/,,x1c2 3
Date: t Approved By: / —.2-,
r
Building Official(or gn EMAIL ADD
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes U No
Water Resource Protection District: Within 100 ft. of Wetlands:
0 Yes 0 No 0 Yes ❑ No
The Commonwealth of Massachusetts
► n IDepartment of Industrial Accidents
i 1 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): C LS /34/NE u/[7 R 5
Address: a rA,rot5tN LAI •
•
City/State/Zip:53 y i1 VARrvlowtfi 6)46 t/ Phone #: .417 g 2-7 3 V`/2
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.IZ I 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
` 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]
10 ❑ 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.
- 12.0 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.:
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.
I.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 cej*fy/under the p and penalties of perjury that the information provided above is true and correct.
Signature y- ' �¢- Lam- Date: 2-�
Phone#: 1l-1 $017 2 t/t/
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#:
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HIC Registration Complaints
Registration # 139223
Registrant CHRISTOPHER PAINE
Name CHRISTOPHER PAINE
Address 22 DRIFTWOOD LN
City, State Zip S. YARMOUTH, MA 02664
Expiration Date 06/23/2023
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.
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