HomeMy WebLinkAboutBLD-23-001591 �� O�.yR ou WqJ p 1rnJ�A l e : ffi Oce Use Only
'$ � �O` Permit# 3..._e- D:
{�O ..2.1 !Amount ,
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°°°°"°`06-c 'Permit expires 180 days from
;issue date
EXPRESS BUILDING PERMIT APPLICA D
TOWN OF YARMOUTH _ `
Yarmouth Building Department 1
SEP 2 2 2022
1146 Route 28
South Yarmouth, MA 02664 1 1.---- G DEPARTMENT
(508) 398-223 1 Ext. 1261 ay _
CONSTRUCTION ADDRESS: y'y Ail ivl› J in r1 z �,� S , (/ //,
y�/7/eQ
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: 4C S S A-A) RA e-✓A L' .SA�Il e 6/ - kFal -Peo G
N ` PRESENT ADD SS TEL. #
CONTRACTOR: /f4ZL ? (�N PA-V po S,[I7 76. /' . 7/4-6( e
J � W ��
NAME MAILING ADDRESS TEL.# 77'( at 3cr S d3 A
❑Residential 0 Commercial Est. Cost of Construction$ /p!y 9 3 /
Home Improvement Contractor Lie.# i it( f , V Construction Supervisor Lic.# CO Q 7
Workman's Compensation Insurance:ill
one)
❑ I am the homeowner 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: #/7 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:W 1 3 A rL iv s j A 13 i f
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 ati of y license and y7 prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: p ,�([/'��%'PLC Date: 9 /070 I 0 0
Owners Signature(or attachment) Date:Approved By: A �j
`Date: 72-
Building Offici r desi EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes E No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes ❑ No 0 Yes ❑ No
_ _ The Commonwealth of Massachusetts
' _ Department of Industrial Accidents
•
, Zit—. 1 Congress Street, Suite 100
f._a �-<" Boston, MA 02114-2017
,s.•`'�y 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): l2c-AI -C P P GA.7ZAl car
ti
Address: 70 £3D x 76
oa66 F--
City/State/Zip:W.WBAis p\A Phone #: 774, 3&-- a'G
Are you an employer?Check the appropriate box: Type of project(required):
I.0 I m 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.]
3. I am a homeowner doing all work myself. 9. C Demolition
❑ y [No workers'comp. insurance required.]t
4.0 I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 Building addition
. ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no em• ployees.
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.El Roof 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.❑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:
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 cer ' n t e • and nalties of perjury that the information provided above is true and correct.
Signature: Date: 9/07471 _
Phone#: 7 > hl 2 6 3(9_
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#:
RICI Ii\R1) I'. (iiRNI ,A( I, .IR.
I'OS I. OF F IC : BOX 476
W4'F.S I DARNS 1'ABI :, MA 01668
774.2 8.86P?
(I«ner's Authorisation
Job Address: 44 Wind Jammer Lane. South Yarmouth. MA 02664
.r t CAC)
, as Owner of the above-referenced subject
property hcrehv authorise. Richard P. Gat-neat!, Jr., to act on my behalf. in all matters relative to
work authorized by this building permit application for:
44 Wind Jammer I_an<. South Yarmouth. NiA 02664
CV- \raft
onature of Owner Date
Print Name
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