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Home My WebLink AboutBLD-23-005546 • 0i•YA..kir RECEIVED Office Use Only is �i (D_Z3-60 o y APR 05 2023 Amounti itR6.oU 4"^""°%c ";Permit expires 180 days from BUILDING DEPARTMENT issue date By: GASH EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 / (508) 398-2231 Ext. 1261 IQ CONSTRUCTION ADDRESS: U N 16 /1 EA/Al, Q� P. �.1 X YVI U v 114 i Al ASSESSOR'S INFORMATION: Mdcie1 yrMaap:: 0Parcel: �( 77 7OWNER: �l v 1r J 1�_ 5r 7 F r n 11 Dw0 f Potna )- / ! - o NAME,( �M PRESENT ADDRESS ./�.r l r— TEL. # CONTRACTOR: /�i►rld/Ula �j t)r s ��'�rvsrn��,C� >��vr U�.y/ �'1Ql) NAME AILING ADDRESS TEL.# SO8-c/(fro (01. ,esidential ❑Commercial Est.Cost of Construction$ t C , cda Home Improvement Contractor Lic.# /(/q/I/ 7 Construction Supervisor Lic.# CS//O 7.58 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor XI have Worker's Compensation Insurance Insurance Company Name: THE HA eYF (. (2 0 Worker's Comp.Policy# 08 W E C L E 7 00 S WORK TO BE PERFORMED Tent 7 Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 0 Replacement windows: # ,2,2—. Replacement doors: # Roofing: #of Squares . (W)Remove existing*(max.2 layers) Insulation nOld Kings Highway/Historic Dist. Replacing like for like Pool fencing I *The debris will be disposed of at: / /r``moon-1 i' Atv S F E►` 7/ 7) t Location of Facility I declare under penalties of perju that the • ent erein 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 o ocatio f n lic e and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: / J/ Date: Owners Signature(or attachment) Date: �r— Approved By: `� Date: `, 3 Building Official desi e) EMAIL AD . S: Zoning District: Historical District: I Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes it No Yes .... No _ The Commonwealth of Massachusetts mor Department of Industrial Accidents =;et:rl- 1 Congress Street, Suite 100 _ ;;ls Boston, MA 02114-2017 \.... '•`'y 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): (IO5('jrE i ofe'er,f...'_ee) (i ."2_j Address: If 03 /, .1'C oL.,,.., K$ City/State/Zip:f-1-yvKAJ 1 5/P1r91024 o! Phone#: 50k Si` (.) c ,i —1., Are you an employer?Check the appropriate box: Type of project(required): i. amam a employer with employees(full and/or part-time).* 7. ❑New construction 2 I am a sole proprietor or partnership and have no employees working for me in g 8. Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑Demolition ❑ y [No workers'comp.insurance required.] 4.0I am a homeowner and will be hiring contractors to conduct all work on mYProPrtY� e I will 10 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. 13.0Roof 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 MGL c. 14. 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: /MKT Ai►t.1) Policy#or Self-ins.Lic.#: Expiration Date: '7—/ ?3 Job Site Address: ri-7 M't 4 tJIL iP o City/State/Zip: . •YWZrr(U v)f►1 , MA 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ;er the pains gnd Pena 'es of perjury that the information provided t ,above is true and correct. Signature:77 — Date: c! `23 Phone#: -5N S I y v t.e y Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: c'. Division of Professional ►censure ,, Board of Building Re ulafions and Standards a: Cons$\r tiA6 rvisoroff CS-110758 spires: 07'30f70; RAYMOND J EDWA'? 80 CONSTANCE AV WEST YARMOO,ITH y 3= <% S a }+ '• C Om m iss i o ne r ,4 K. 8i�i�rrithk_, 0 ,i-d-"Ze Kt/74/2'40-/-4(1)egi 0-/ Ki-)-4K7-ci« ,e/-`4, Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual - L IA 1? Registration: 144174 11 I Expiration: 08/16/2023 RAYMOND EDWARDS - i' .-- 7„4 l 80 CONSTANCE AVE "' 4 Yfl W. YARMOUTH, MA 02673 i1.b,1 4 5n. ^�yg� 4 jai f ,, t`t.'' v ; '' Update Address and Return Card. 3CA 1 0 20M-05/17 //P (iiv M1 /'////'/'ir�f7 V. /(iCliff/////// %//i Office of Consumer Affairs& Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: Individual - before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 144174 08/16/2023 1000 Washington Street -Suite 710 Boston, MA 02118 RAYMOND'EDWARDS • RAYMOND J. EDWARDS 80 CONSTANCE AVE �,7.•a1�6 ,'/ Not valid without signature W. YARMOUTH, MA 02673 Undersecretary