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HomeMy WebLinkAboutBLD-23-006060 01 Yx p 5,ii'/? Office use only Permit#t� / 0 .. ! Amount Li Permit expires 180 days from issue date IA A Goa EXPRESS BUILDING PERMIT APPLIC TOWN OF YARMOUTH 1_V Yarmouth Building Department 1146 Route 28 �MAY 0 2 2023 South Yarmouth,MA 02664 __ ._ G (508) 398-2231 Ext. 1261 BUILD CONSTRUCTION ADDRESS. J ./LIa eC `K W0 VIe JI"+'I ©.Z i'v7j? ASSESSOR'S INFORMATION: Map: Parcel: OWNER: !(1 Cr7C '0 4 CSaw,t (le s 4.kovc� 5a8 3.2 s ( ?O NAME Q/ PRESENT( � ADDRESS TEL. Q IA,� TEL. # Q� (/ CONTRACTOR: v� C .rQl4o S6� 5 _ _ /`�T 13 ev%r Irt l�U L�D �1iff NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ 27, l Home Improvement Contractor Lie.# pr%oZ tf Q`( Construction Supervisor Lie.# C_S --/Of et V Workman's Compensation Insurance:Aeck one) 0 I am the homeowner v1.!'I am the sole proprietor 0 I have Worker's Compensation Insuranc Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent 1:1Duration (Fire Retardant Certificate attached?) Wood Stove ❑ Siding: #of Squares AO Replacement windows:# Replacement doors: # 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: y i 1' ___ cl l'r'r l„t(n M.W Location of Facility I declare under penalties of p ' . 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, -"cation my liven and for prosecution under M.G.L.Ch.268,Section 1. / r1 Applicant's Signature: Date: l� ci -1 f 1 /ri�3 Owners Signature(or bment) Date: Approved By:_ Date: �"� Building Official(o� EMAIL ADDRES : ;Q�N �V Q i&�i A7r r v�'T701� Q� oral 1 .cam Zoning District: Historical District: L1` Yes "' No Flood Plain Zone: "i Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No D Yes D No / 'it ropotiat Page# of pages \ K,Va 0140 i e, :2.5L.,--: C — 1O0Vie? .66 Kottli H/c : ,ci • e - fF 3/ 7g q qq 1,61/, PROPOSAL SUBMITTED TO: JOB NAME JOB# ADDRESS. JOB LOCATION A DATE DATE OF PLANS W( Ii' }d, toj t / Apt FAX ,2 ARCHITECT PHONE# 51, 3a S 6U j / e hereby submit specifications and estimates for: _-_ __ .____._ 5 r_.._ . _ . .__.1_ r 11 Pet,v _Apt _ — sty Ord r i ._ , i4-. lifieZtj _ - - _ PVC _ r �.__ . r . h2carIc-. ._ ►'. I }r_. ; . to) — — Cl/kJ- up d_ _w2 _itiiii4 I I a k-- _- i_1 - - L / GI -s 4 'iif\ .__ Ndi tteA_ . .;... aOt z Oil pera viC( Pam_._ 1 _._b. _ __ s 41 i4t ac i_ 1_c- Slim _ iva e propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of \ 1'"t •. Dollars r ` �� /�� 1 with payments to be made as follows: �:.��� ' �� ''-- 41 ."' l '. `A Any alteration or deviation from above specii ications involving extra costs Respectfully j i will be executed only upon written order,and will become an extra charge submitted over and above the estimate. All agreements contingent upon strikes, \accidents,or delays beyond our control. Note this proposal may b accepted within days. acceptance of �ro�o��r \ 2 �, -7 , —,'eX The above prices,specifications and conditions are satisfactory and are ,. ," {--- ,7 / -.--.."..:------- hereby accepted. You are authorized to do the work as specified, Signature Payments will be made as outlined above. Date of Acceptance l ° -- Signature A•NC3819/T-3850.09-11 . The Commonwealth of Massachusetts cam /, Department of Industrial Accidents trait'lit= 1 Congress Street, Suite 100 r Boston, MA 02114-2017 `t 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/IndividuaI): Cif,v K v6 C KC , Address: g (Q Ce SSuckell /Q7, City/State/Zip: 6refidkr 1 kV Oa(,3 f Phone#: rze W& &(p/? 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 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t 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.QElectrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.12I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs Tt�se sub-contractors have employees and have workers'comp.insurance.; 6. a are a corporation and its officers have exercised their right of exemption per MGL c. I4. Other S��t Liq 152,§I(4),and we have no employees.[No workers'comp.insurance required.] �JJ *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: ? �lihiatiflAi4U City/State/Zip: We *mid&/f4Pr cat,73 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 verifica'on. I do hereby c nder t e pains and penalties of perjury that the information provided above is true and correct Signature: Date: A / j 2O2 3 Phone#: 1 I too (l&iq 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: g K ,44i:i r .�,is ,, a 5;'; '54 Vi,• ,.. , Ifsie ;rs ,4 % y' ..,� • .',L4 s �� s�P yY�< i' � ro fi444,fb, t.. 'Ittft cr ii,'�� � 3? .a<' ,; %£ tip. � n � „ sg,Ml%. .,;"`so,'x %asA .'. .,Q ems° � IIE i!< .. •< „ ate • a 41', ,:tt ' }<r »,',',... ", "'. - °, ' ,fie, Itk x -•..a:•#,.. ..a• " •;K�... ':";" '.. ,2`°''•°, '''• <r•'.,� :ice ° P, Yu,} - & "`' -SvSs'r re"a°r ..:hY' ''3,:<' .SKs : '�<'< :.4 ..fie. 4 }' L a� f.:.x iy..1. =ID< • 1 x& <„„4,::y ire:, ;:r•'.<}'oa " Vi.. " }iq 'S�R ^- `. k 'V`?A3'4' Yi`sw.'^f'rh. •.:.4 Y' A}`'"<,.Y'<�1,:,:.fr k .;':..: • 1 .7 it µme w° , F .�: .p< {-° • .. -, • ,: ,� ems,'•;,, , '< ':-z �;, .. # '- :,.• 'a • �. a ma.