HomeMy WebLinkAboutBLD-23-003431 011"Y44 Office Use Only
k• ', o iZl2a (Z . RECEIVED
3.333
v LP .t#
ermit expires 180 days from .tssue date
BUILDING DEPARTMENT 61D
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) S398-2231 Ext 1261 „
CONSTRUCTION ADDRESS: "IL / G O(� Won At
�`
ASSESSOR'S INFORMATION: , `IMap: Parcel: A
OWNER: \4
NAME )�, " 0-') C�Cis� (,Cj 1. ' S 5 l�fC"c ' kELNAMPRES T ADR�S}\ \ #
CONTRACTOR: a-7, c�&- lam- ^r L` �� C N-1 Q`. , W 1 ^' T CIA S (i 1 t �1 MAILING ADDRESS �^ TEL.#
❑Residential ommercial l xx
Est.Cost of Construction$ I. U�6
Home Improvement Contractor Lic.#
kc-tZ\ l Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner ❑ I am the sole proprietor leave Worker's Compensation Insurance
Insurance Company Name: �1C� Worker's Comp.Polic '73 , f�
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
El
+n
Siding;#of Squares 6 Replacement windows:# Replacement doors: #
Roofing: #of Squares (❑)Remove existing*(max.2 layers) n
Insulation l l
Old Kings Highway/Historic Dist. Replacing like for like Pool fencing I I n
*The ?)
debris will be disposed of at: C r 1 / /��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 o : ".n of my li . and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature:
Date: / Z D
Awr
Owners Signature(or attachment) I ,�� / i , Z
it 7717
Approved By:
Building Official(o . sign• EMAIL AD)",SS.
;
SS:
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes ,. No
Water Resource Protection District:
Within 100 ft.of Wetlands:
Yes No
Yes No
;.:„
Commonwealth of Massachusetts
1
IP Division of Professional Licensure i Beard of Building Regulations and Standards
ConsgtibtAtAiipArvisor *
2,,, /
CS-075281 - ',';'1 *!...pires:03/12/2023
10 ECHO ROs:1 f '.41". t•.,-• ,...%--,
WEST YARMOyTtt
?,
• " "
iliONSti3C0
Commissioner d'oefa K 8/6,7;17,,,t_
THE C081::: r Tri,t1:13m:AssinsAescsHitueserTs
....me 0 Affat .,
,.... f ......wEALTH co
--
HOME gulation ,
kr.MgazikITRAcToR
CANTARA 13111441"1-7:-" ..."'
TODD CANTARA s S, -t--:--•::' -- 24
I
1:0:EDC:HCOA NR RD.
.'"PP.
6V-- ;• •
zi
) YARMOUTH ki ,.,
W.* A 0264., "*.r :144,11.4gOra//
,_,..... ,..lf., V ................. 1 ..........!..,..04..
Undersecretary
' ,,.J The Commonwealth of Massachusetts
� ►._=M Department of Industrial Accidents
v/Il- ' 1 Congress Street, Suite 100
'�_ _—Y Boston, MA 02114-2017
� �� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A Iicant I formation
Please Print L ibl
Name (Business/Organization/Individual): ,
Address: l`b ; ,,
City/State/Zip:`,J t.- &-rt",,,0t,, PIA Phone #:
Are you an employer?Check the appropriate box:
1. t<am a employer with __employees(full and/or part-time).* Type of project(required):
2.0{am a sole proprietor or partnership and have no employees working for me in 7. 0 New construction
any capacity.[No workers'comp.insurance required.] g• 0 Remodeling
" 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4.EI I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition
• ensure that all contractors either have workers'compensation insurance or are sole
. proprietors with no employees; 11. Electrical repairs or additions
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.These sub-contractors have employees and have workers'comp.insurance.* li. ,R(oof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14 tuberStVet
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: 110\t
Policy#or Self-ins.Lic.#:_L►CC ) !7 i l �
.�_ Expiration Date: aZ, 22,
Job Site Address: f� �n/e. C.�
Attach a copy of the workers' compensation policy declaration page(showing the policy num beer and ex irattiio n date
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1500.00)•
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 c he p fP penalties o pains and perjury u that the information provided above is'rue'and correct.
p
S ature:
P one#: Date: 6 Zi
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):
6O
1.
Boardh of Health 2, Building Department 3, City/Town Clerk 4. Electrical Inspector 5. Plumbing
,OtherInspector
Contact Person:
Phone#: