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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department1
_•,r
D eA C) 1146 Route 28
��� ���� South Yarmouth, MA 02664 MAY 17 2013
(508) 398-2231 Ext. 1261
' IBUILDING DEPARTMENT
CONSTRUCTION ADDRESS: C,) - V�`l� L 4l. S•S. q'ot iz..WIU, ma By
ASSESSOR'S INFORMATION:
t Map: Parcel:
OWNER: Lei( a rr W),-11 i RJW1.1 > - uS l.[/' I —a. '
NAME PRESENT ADDRESS
• TEL. # � �
CONTRACTOR: d SF W Lid N ' �.� $30ditdc.VVI '‘0?).--43k-4Q Z (o
N MAILING ADDREa TEL.#
'Residential 0 Commercial Est.Cost of Construction$ 4(J'(Dc))
Home Improvement Contractor Lic.# E 1 1,l,Lk C:? Construction Supervisor Lic.# QLtO j 4,'Z
Workman's Compensation Insurance: check one)
0 I am the homeowner Y I am the sole proprietor d I have Worker's Compensation Insurance
Insurance Company Name: 1.115e4 k , M.,.k.-.,cvl Worker's Comp.Policy#
WORK TO BE PERFORMED y 4- _ W L GO tki`UR-k-
Tent Duration (Fire Retardant Certificate attached?) �° �°
Wood Stove /
Siding: #of Squares i U\ Replacement windows: # 94 \1°.• Replacement doors: # \ in i-e1 d/
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: /cj.t?.
(110JL -±17,Q,cvSL'e-, Yr t a�10 A-
i Location of Facility
I declare under penalties of perju . I'- 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 re o • • t license and for prosecution under M.G.L.Ch.268,Section I. s
Applicant's Signature: Date: v I L• k_S
Owners Signature(or attachment) j. .1� Date: ('3 ' t 1• 7,
Approved By: ter' Date: o es 1:3"r3
Building Official(or signee) EMAIL ADDRESS: (;Pt C'1./ w 04d
y,` j de-P 0 t
Zoning M istrict: (Wined Wine(P �7L
Historical District: 0 Yes No Flood Plain Zone: ❑ Yes No
Water Resource Protection District: Within 100 ft.of Wands:
0 Yes DI No 0 Yes No
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constgv tihtlAi isor
, I
CS-040822 ,�'
*
THOMAS CjPires: 10/25/2023
246 COUNTO _Ir
BOURNE MA • ,
Commissioner d,et K. 116„cuf�
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
HOME IMPROVER ENt CONTRACTOR
TPE n j iyidual orR i t i n
25
THOMAS C.SPENCE. ..,
THOMAS C.SPENCE ;'
245 COUNTY RD. 11x'� :
BOURNE,MA 02532 ' ', �� �•�
Undersecretary •
•
_ �'�� The Commonwealth of Massachusetts
f` 1. Department of Industrial Accidents
I* 1 Congress Street, Suite 100
A"UF i." Boston, MA 02114-2017
. -4-..:"\ 5�,�'`tir
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): UvVICt,) (cpc,,,,)
Address: 143 e oo.A.k ci Pic: ),-.a,c, ii . c2,532)
City/State/Zip: Phone #: ,ij68, 4 3 x- `{q 7 G
Are you an employer?Check the appropriate box:
Type of project(required):
1.LJ I am 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 8. n,Remodeling
any capacity.[No workers'comp.insurance required.] u�
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.❑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
6.E We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑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: L _
t, I o</� ..G-e'4- ' j 7O O c)
Policy#or Self-ins. Lic. #: C -3( 5-C.2Z03(a C) LA Expiration Date: & -1 0- 7.c'1.3
Job Site Address: Cr.. 1 (P-L1(y La City/State/Zip: .�d,v?, &)It (1)6.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 ce tz ifin e z ains and penalties of perjury that the information provided above is true and correct.
Signature: - Date: S -I, [- VD
Phone#: 'O8-41) `kq 1
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#: