HomeMy WebLinkAboutBLD-23-005859 O .y-- ii Office Use Only 7
4' �! 0' Permit# 24
O '' 1'A �"� !Amount 5Z
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` _a"0""" p Permit expires 180 days from
I issue date
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EXPRESS BUILDING PERMIT APPLICA
TOWN OF YARMOUTH C_ E - V E
Yarmouth Building Department
1146 Route 28 APR 2 0 2023
South Yarmouth, MA 02664 i_.- __ _.
(508) 398-2231 Ext. 1261 BWLDING DEPARTMENT
By.
CONSTRUCTION ADDRESS: J 3 s 1 (od rI ii v 1 y AA m6u.t ( M. / 1 0 JC6'4
ASSESSOR'S INFORMATION:
� r Map: Parcel:
OWNER: 0 bNAM(,"r 0 < oL I+ i j k_� PRESENT ADDRESS .0 #3 C- 0 S 11
CONTRACTOR: p 1 ( la C d t-r t*.4 A' t l b g i Cj 17 i fl 0 $I.,(/p (CA 2 ve--/Lt/v‘ ft 'f IJICI)
NAME MAILING ADDRESS TEL.#
t Residential ❑Commercial Est.Cost of Construction$ <6/ 500
Home Improvement Contractor Lie.# 00 6._4 °' ( Construction Supervisor Lie.# C5 1 , 3 1 t J
Workman's Compensation Insurance: (check one)
0 I am the homeowner ❑ I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: pO(U'4 t_9 I MC—: DCI`lLQS Worker's Comp.Policy# VA- V 0 ,�q® 154
Nv�' �hN� W 0 BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows: # Replacement doors: #
Roofing: #of Squares 11 ( //)Remove existing* (max.2 layers) Insulation
C/O 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.r revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
,,� a �l / zc a 23
Applicant's Signature: � �, Date:
Owners Signature(or attachment) r:3J A E . '' :art Date: 0 V eg c)2
Approved By: 4 Date: 9-2-1— i'3
Building Official(or"- ign EMAIL ADD'J :
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes 0 No 0 Yes 1 No
The Commonwealth of Massachusetts
_+�, = Department of Industrial Accidents
_ttet- 1= 1 Congress Street, Suite 100
_ t��= Boston, MA 02114-2017
,5�.,› 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): -' Q 1, Crpth 3 cN T •l 1 N C
Address: t.IA t (LA Q r0(1..57 D [,it r CAI AAA i 0.2_ b.3 0
City/State/Zip: CA 4 it t.ti, An la 1 0,Z 3 O Phone #: -4 4 i,2 S 9 (4 3
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. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself. 9. ❑ Demolition
y [No workers'comp.insurance required.]
4.❑ my
I am a homeowner and will be hiring contractors to conduct all work on property. I will 10 Building addition
. ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
pr netors with no employees.
12.0 PI bing repairs or additions
5. am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1-, oof repairs
These sub-contractors have employees and have workers'comp. insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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: VOL ) 7. AA C WI.0 s \f ) Ult A N Cr" A. r CN C
Policy#or Self-ins.Lic. #: ?A VC _. (i\ 6 2 $u Expiration Date: 0 710 1'(OW 2,
Job Site Address: 2. 3 kf p'i- ib4_c)c)ti 0 1 A/:v>.c'xaTh City/State/Zip: ( k A ( 0 L.{
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 u the ins and penalties of perjury that the information provided above is true and correct.
Signature: Date: 0 G(/ 29/c g'3
Phone#: 7 L( 1--/ S 4 6 G 9.-A
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 Affairs and Business Regulation
1000 Washington= rt; Suite 710
Boston,.Massachusetts 0 118
Home Impro Tlenf( ntr or Re Istration
,, # Type: Corporation
J&R CARPENTRY INCORPORATED Registration: 206331
14 BRADFORD BLVD E#Piration: 08/26/2024
CARVER,MA 02330
x
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT.cONTRACTOR expiration date. If found return to:
TYPE t&p&auan Office of Consumer Affairs and Business Regulation
Regst allon -Imitation 1000 Washington Street-Suite 710
2063a1' z =,-:08128t2024 Boston,MA 02118
J&R CARPENTRY IN RPC,ATFL}
t
fieDIEGO P.OLIVEIRA
14 BRADFORD BLVD ,m ���
CARVER,MA 023302
Undersecretary Not valid without signature
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