Loading...
HomeMy WebLinkAboutBLD-23-005930 -- .YR (� f �7 Office Use Only `_ R`tr L / /;Jl // ,� i Permit# 4)2c �� O , 0 . 1l s , !Amount S �nATTACM est L °+oo.n104 E.. Permit expires 180 days from issue date 8CD -43 -0,56t3O EXPRESS BUILDING PERMIT APPLICA TOWN OF YARMOUTH ••_-PEIVPD Yarmouth Building Department [APR 1146 Route 28 2023 South Yarmouth, MA 02664 BUILDING oEPARTM- (508) 398-2231 Ext. 1261 By,_ LveS 4' CONSTRUCTION ADDRESS: ` ° Q t t)(f i ti S 1 A.111 i VAIt! irn+ i !►n4 1 6,2 G 73 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: m h (� I MENDez Sag Is' 0sct NAME PRESENT ADDRESS TEL. # CONTRACTOR: D (Er Co 0 ll ti i R `L\ IL )( ) Q %I� �}(Z 1 CvcO. .pin l *)7- �1 4�'7 6-6-71 NAME MAILINGADDRESS TEL. d Residential ❑Commercial Est.Cost of Construction$ J666, 00 Home Improvement Contractor Lie.# d © ( 331 Construction Supervisor Lic.# C. S I I 1 11 /1 Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: Do yu p ) McOqenl,'p_OS Worker's Comp.Policy# p p V 0 31 ( 25 4 I N S At A P C t- WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement/� windows:# Replacement doors: # Roofing: #of Squares ( ( " )Remove existing* (max.2 layers) Insulation l v l t9 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 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: t, Date: Owners Signature(or attachment) (IA/IVA CA D L'`L Date: 0 Li(9 5 ( t ) a 3 Approved By: Date: a/_t� ) / ) jc 23 Building Official de . ee EMAIL AD S: "`l °[J Zoning District: Historical District: 0 Yes 2 No Flood Plain Zone: u Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes ❑ No - ' * • The Commonwealth of Massachusetts - 1=W = L Department of Industrial Accidents t=wis1— 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): 5(}p/0 \I- C A(U)EIV t!.-( i N Co/- P©fL. t c o Address: } L i j l?A V. V01 k) ' v City/State/Zip: CAK AAft 02330 Phone #: 4 7 4 t-is 9 /CC/4 r)/- , 7 ci J`3 3 S Are you an employer?Check the appropriate box: Type of project(required): l.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• ❑ Remodeling 3.0 I am a homeowner doing all work myself 9. ❑ Demolition y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on property.mY I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions .roprietors with no employees. 12.E Plumbing repairs or additions 5.rA I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.; 13.Q Roof repairs 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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: Do J/At b 7 jv�.E Oc u', c s Policy#or Self-ins. Lic. #: 'PO V 63 l 02 54 Expiration Date: ` © 2®n2 S �. 3 Job Site Address: 6 •f}-h,b U TOS p1VV Y fk oiti wit- City/State/Zip: y d TN , E O,2 6 f 22 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). J 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: 1' 11 l ( .2_5 / Date: ,,Z0 Phone#: 7-.3- t-4 1 SCi 4) 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#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affaiit and Business Regulation 1000 Washing ., . rtz Suite 710 Bostort Massachusetts og 118 Home Impro :rrientIO tractor Registration Type: Corporation J&R CARPENTRY INCORPORATED ti eg'Oation: 206331 Expiration: 08/26/2024 14 BRADFORD BLVD CARVER,MA 02330 E 4 : f gun v.. '" Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Malts&Business Regulation Registration valid for individual use only before the HOME IMPROVEMMNiCONTRACTOR expiration date. If found return to: TVPE,t:orporation Office of Consumer Affairs and Business Regulation Bettlattalien EX0initlor 1000 Washington Street-Suite 710 206331" _4 88/251 Q24 Boston,MA 02118 J&R CARPENTRY INgTFQ DIEGO P.OLIVEIRA 14 BRADFORD BLVD .�; r�i_. .a..,� �s�-r■-C�-+�-v� CARVER MA 02330 O Undersecretary Not valid without signature Ay a 0 3 C 0 .. gig ' 0 • 2:) Cl47 a MO `Y1 0 liwN lig 44 F. ' - ''''. ,. V 44 'Aft.. 1 t ,, �m � *— 0 ��y I' xr lig Vie` bid r. , 3 �� " x . may: = . 0 . i s di z a w r' r� gi !Arg "�yi /i isAilit 411 0 .41,11 r�L ' f A icy fir ..y .o: y,, :.. ;,. i tr II V - sy /* '