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HomeMy WebLinkAboutBLD-22-007168 Office Use Only +1�.. �Permit# et,02he O �, HC. Amount J Q, d-0 FPermit expires 180 days from cam: issue date 13 D-, OZ - 66 q/Cog EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH �1' Ga) /VD OR Yarmouth Building Department mot' 1146 Route 28 C T"C// ),�,, ?r South Yarmouth, MA 02664 RECEIVED (508)398-2231 Ext. 1261 ---- - --- n CONSTRUCTION ADDRESS: 7 Vo L N ll A'CL- AVE 'J U N 1 U 2U22 ASSESSOR'S INFORMATION: BUILDING DEPARTMENT Map: Parcel: By. — /' OWNER: SAm uu t5 Tt E NB GN APRES//f%NoENT ADDRESS / Rayed'4Op 40L. # j3-6?E'0 NAME ee pp M .�/ w�Ap fix o' �y�.-p� CONTRACTOR: mPJ& T V L t-n 7 Cvmsr• i�t� w `/ wily, s-or O / --`` / NAME MAILING DRESS / # Bxesidential 0 Commercial J �p� Est.Cost of Construction S/ / SD 0/ Home Improvement Contractor Lic.# 16.7, O 1 Construction Supervisor Lic.# /d ye)7 b Workman's Compensation Insurance: (check one) �/ ❑ I am the homeowner 0 I am the sole proprietor Q 1 have Worker's Compensation Insurance C . op Insurance Company Name: Z viz ) Worker's Comp.Policy# U 6 6 R V s) 7 5- WORK WORK TO BE PERFORMED Tent J__.i Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares u Replacement windows:# Replacement doors: # Roofing: #of Squares ( ,'- (❑)Remove existing*(max.2 layers) Insulation n n Old Kings Highway/Historic Dist. cp Replacing like for like Pool fencing I I *The debris will be disposed of at VA c in o u Do f l 1 V 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 or revocation of my license and for pr ecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ��'�tAra.fm Date: /U-24.? I. Owners Signature(or attachment) 'r 1�C' 2-y ,, Date: > 7s,//' i �.) Approved By: �[Al Date: ��� �? Building Official(or desig e E L ADDRESS: Zoning District: Historical District: :J Yes " No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes -! No -7 Yes I No The Commonwealth of Massachusetts t Department of Industrial Accidents tyl= 1 Congress Street,Suite 100 moils Boston,MA 02114-2017 ti www.rnass.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): fr 44k K rnLL L!111 Address: `7 C 0 N NC 1141&4 w i ' City/State/Zip: 4).y4 gfl e t;re W\4 Phone#: S-O a?›.1 31! Are you an employer?Check the appropriate box: Type of project(required): 1. a employer with 3 employees(full and/or part-time).* 7. New construction 2.01 am a sole proprietor or rnutnership and have no employees working for 1e in 8. Ej Remodeling any capacity.[No workers'comp.insurance required.) 3.01 am a homeowner doing all work myself[No comp.insurance required) workers' t 9. El Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole I 1.DElectrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.121 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.DWe are a corporation and its officers have exercised their right of exe 14.D0ther 152,§1(4),and we have no employeesmeson a MGL c. .[No workers'comp.insurance required.) *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy u,fiu union. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. lithe 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: 2, U C... K Policy#or Self-ins.Lic.#: () 3(,R 3) 5' 7 7 S Expiration Date: 3 ! ?- t �� Job Site Address: ( Td ui - \A1L AV 6 City/State/Zip: Y4 O DT H J✓tA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).073 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 under the pains and ' of perjury that the information provided above is true and correct. Signature: Date: fa -/D" ;e g Phone#: ro s- 22( T 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#: ilfCommonwealth of Massachusetts Division of Occupational Licensure Board of Building R ulations and Standards Cons gm"'io rvisor CS-104076 1 i pires:09/07/2023 MARK M MU 7 CONNEMAk , J • WEST YARM61 ,k• at. 0 Commissioner daiia K. BtiQ THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer AffaMB&Business Regulation HOME IMPROVEM tcCNTRACTOR T�YPHoran©r� a.t •n 1 x l fi MULLIN ROOFING AlieptfilD I MARK MULLIN - 4 , 7 CONNEMARA WAY • co.'*'0(a,1 - W.YARMOUTH,MA 02673, ; Undersecretary •