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HomeMy WebLinkAboutBLD-23-005762 /� ' Office Use Only o R Wt 0 3d 3 • • .!! `� 17- '3 j Permit# 7 J f l ,/g ' :Amount 5T OD •�� HATTA H [SEr�' ,,,,,�st.0 d r 1Permit expires 180 days from :: i"-:-,.; ;issue date 8 19D -013— 66 12) EXPRESS BUILDING PERMIT APPLICATION S-7(02._ TOWN OF YARMOUTH Yarmouth Building Department R E C E 1 V L D 1146 Route 28 South Yarmouth, MA 02664 APR 14 r023J (508) 398-2231 Ext. 1261 " P�('(! BUILDING DEPARTMENT CONSTRUCTION ADDRESS: �1-1 �O L �„� Ou44 BY ASSESSOR'S INFORMATION: Map: Parcel: OWNER: G0r'l_ ikrie Ct.ZZec 'n( 1 G CA gr",...n. roft © - is 014) 930—t{I�0 NAMEE PRESENT ADDRESS TEL. # A CONTRACTOR: ¶ �•.cl/J (ao.. X 1144.dcrn.lni Li.. ft104.;s1MA- o240 7 4) 5-21'7.1).Y.7 NAME MAILING ADDRESS TEL.# V.Residential ❑Commercial Est.Cost of Construction$ /0,oid" Home Improvement Contractor Lic.# /(176.2 y Construction Supervisor Lic.# 6.74 83? Workman's Compensation Insurance: (check one) ❑ I am the homeowner I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: /')IA 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 g•l ( )Remove existing* (max. 2 layers) Insulation k Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing 0t- WI Li Iu ft()ite- r - Li/t(dP3 f /��,ry,�i *The debris will be disposed of at: V r) ` `f�- i,t t_ U 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. 1 Applicant's Signature: � l N Date: (yJ�oL3 Owners Signature(o attachmen) 4/"Z/a......_ Date: Approved By: Date: � .2. Building Official esign EMAIL ADD Zoning District: Historical District: ❑ Yes U No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts r =;. / Department of Industrial Accidents 1 Congress Street, Suite 100 __��__ Boston, MA 02114-2017 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): SGl nuc( C, Aoki I-. Address: —7L Ui4cr,.a„f / City/State/Zip: L' 4"0S /LLA oac o, Phone #: {`l ? ) 5:24 —7 PPS- Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.41 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] ` 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 10 ❑ Building addition 4.0I 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. 1;.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance. /� c 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other (�-°� ''� J(.1l`"1L�p`wT 152,§1(4),and we have.no employees. [No workers'comp. insurance required.] J *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: ) IA Policy#or Self-ins.Lic.#: /V IA Expiration Date: AEA Job Site Address: ' 'i)I 1Z+- CiA City/State/Zip: Yam•-)- Pelt AA 624.75 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: y i ao a3 Phone#: -91 ) '5 2 I 7PP 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#: / !R®eL L aA- SECTION S: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.Its City/Town,State,ZIP R Restricted lde2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition , 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC HIC Registration Number Expiration Date P y Registrant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(1VLG.L.c.152.§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit, Signed Affidavit Attached? Yes..........D No .........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize .-Cm o'-I //a ear) to act on my behalf,in all matters relative to work authorized by this building permit application. Print Ow?er's Name(Electronic Signature Dam • SECTION 7b:OWNER OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) ' Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will NA have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www,mass.ggov/oca Information on the Construction Supervisor License can be found at www.mass,aov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfxbat s Type of heating system Number of decks/porches Type of cooling system Enclosed Opal 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Constoitil6 5144,rvisor CS-096833 Et.pires: 11/10/2024 SAMUEL.F NN6O0M''f41110, 76 VANDERIINNT L 'all 4,4 HYANNIS MAAfl28411 4,-`•4 x 44O7,r,va D 4, Commissioner daa bt„ • ;oke.of©nsume l Ye s � � OCl dtion HOME IMPROVEMENT CONTRACTOR ' • TYPE:Individual Registration Expiration 144 07/24/2023 SAM NAOOM SAMUEL F.NAOOM 76 VANDERMINT L•i HYANNIS,MA 02601'; r Undersecretary • • • r