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HomeMy WebLinkAboutBLD-23-006067 OVYRR CG�i.(/ 5/'/2 3 Office Use Only $ C 5'7/, � Permit# //�� //�� O 0 !Amount 5i: ,it u i e MATTACM CSF•� 4*.Mo.,«o�'el?' I i Permit expires 180 days from issue date &3G-/)a 3 j((.0()(i7 EXPRESS BUILDING PERMIT APPLICATI 0! k TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 I MAY 0 3 2023 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By:_ _ __ C ON STRUC TION ADDRESS: 5 LI 3-6V 62- 9`0 f ,� cat 6 ASSESSOR'S INFORMATION: Map: Parcel: Zl S '2 7 4 cA.I e-7 D OWNER: C 4�/-G ` A L, L.le_ in) 6a e v NAME PRESENT ADDRESS TEL..# CONTRACTOR: F I^'4 Ai iv 1.4 t j 11 4 rm. &I I / �-L / 2 4 PG/C '1 AL/4 A( „� NAME MAILING ADDRESS / TEL.# IL&4 4 �fil 3 8 ❑Residential ❑Commercial /� Est.Cost of Construction$ / 2�© 4� Home Improvement Contractor Lic.# l Lr 7'In Construction Supervisor Lic.# G5 t ?8O (O Workman's Compensation Insurance: Sefeck one) ❑ I am the homeowner y 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: # I Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ( G Uv h —ri 014 Ll l i"2._ 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 ense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature i r attachm•nt) Date:L 5 �J�V J� 3 Approved By: / Date: !✓ �i— Building Official(or design MAIL ADDRESS: — Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes No .4 '� The Commonwealth of Massachusetts _; , � /, Department of Industrial Accidents T/11= 1 Congress Street, Suite 100 �� ' Boston, MA 02114-2017 -:rlc ,. www.mass.aov/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): F(.-i l) n?�?A� Address: /to ( hi /cc/- )c fc. gd Al./4/ f *i g 62 3g City/State/Zip: Phone #: 77 1/ 2-I. e 9376 Are you an employer?Check the appropriate box: Type of project(required): l.❑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 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.❑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 5.0 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.t / r � 6. �e are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑�Uther A 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: 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 and ze pains and penalties of perjury that the information provided above is true'and correct. Signature: Date: Si 03/ Z3 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 Phone#: Contact Person: Permit Authorization Form AA r 1 L oc Kd am the Owner/Trustee of the property located at "t,/ Ped0100,- , 5-Li :Mire <; S, l .ov 1 and hereby authorize itnittes-C44erfoises, CLEIDCD LLC to apply for a permit to4-1cr4c},4).(3e) 4 -414 rectr bvf- 3 orvne--- 2-v Z3 Owner Signature Date n,,. , Office of Consumer Affair_&3u:;iness Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 147951 09/23/2023 1 1000 Washjnoton Street -Suite 710 FLYNN HIGH PERFORMANCE,LLC. £ Boston,"7T t 02 18 THOMAS F.FLYNN f 146 HOKUM ROCK RI: f�,..v.�f £, DENNIS.MA 02635 Foot valid without signature Undersecretary j > Commonwealth of Massachusetts / ; Division of Professional Licensure Board of Building Regulations and Standards Const\Pu t/ ,iervisrur r CS-098040 ' Tres: 10/05l2023 THOMAs F "It HOKUM lEh Duns MA G?s39 .t I � 146 D ;�* `C}lSS 1 I0*‘N. Commissioner d K. ,,