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Home My WebLink AboutBLD-22-007334 of'1' RECEIVED Office Use Only 0 l�r� � LclUilel320Lit,27,� Permit# �� ,'ay,.,c. t„ Amount... Permit expires 180 days from BUILDING DEPARTMENT issue date 15LD— —66733zi EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 9 '1'i.' < ASSESSOR'S INFORMATION: Map: Parcel: rr OWNER: r"f.,,v IN h,lv) �, 3a v(C ; „ `1/4 N=ris !`D� NAME PRES 'U \sue 3 Sit'-�1 �' DO ESS__ TEL. # CONTRACTOR: West Dennis, MA 026 l0 (5'L e ) �).e..- _.C 1I( NAME egg tr h-6964 TEL:'# ❑Residential 0 Commercial CSL 7' .133 HIC- '91.konstruction$ )Nc.-- Home Improvement Contractor Lie.# I L`1 y, Construction Supervisor Lie.# CS�;s S Workman's Compensation Insurance: (check one) 1 I am the homeowner G I am the sole proprietor [0/I have Worker's Compensation Insurance Insurance Company Name: ,V£:V, ,I L.,`I, ;4.` + .:k it Z,,..> Worker's Comp.Policy# j1 1 WC o T3 3 I)g WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 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: e XC v Location of Facility I declare under penalties of perjury th t 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 r v y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /f G Date: 6 I?. !J 1 Owners Signature(or attachment), )44k 1, Date: . 4a 1- Approved By: Date: G—A.o Building Off ' or ignee) EMAIL ESS: Zoning District: Historical District: :-_, Yes _' No Flood Plain Zone: , Yes L NoC/Q--" Le Water Resource Protection District: Within 100 ft.of Wetlands: rpaI Yes 1 No Yes UI��No 1 - cc6 3?8 '? DocuSign Envelope ID:FCCD2E69-1F97-4A21-8500-EEC80FC8FA4E C6-1/ _ 93$-C41 ® �/r i2 -ZL RISE ENGINEERING" OWNER AUTHORIZATION FORM Frank Whiting (Owner's Name) owner of the property located at: 8 Snow Brook Road (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize Subcontractor(to be filled in by office) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. o«uSignoa by; Lail& 4F7R2F 8f7F7479 Owner's Signature 2/5/2022 1 6:51 PM EST Date RISE Engineering,a Division of Thielsch Engineering, Inc. 765 Attucks Lane I Hyannis, MA 02601 1508-568-1926 www.RISEengineering.com • „sk The Commonwealth of Massachusetts Department ofindastrial Accidents • = j Congress Street,Suite.100 Boston,MA 02114-2017 • www.mass.govnlia Workers'Compensation Insurance Affidavit:Builders/ContractOrs/Electrkians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. • Applicant Information Please Print Leriblv *Mc Me.-Qurtilty.etnaOrulatipaa Name(Business/Oiganization/IndividuaI): PO Bcis42 Address: West Dennis, MA 02670 Cull-(508)280-6964 • City/State/Zip: **,e.,,, CSL-58ftine WC-169393 • Are you an employer?Check the appropriate box: Type of project(required): 1.04<m a employer with V- employees(full and/or part-time).* 7. El New constiuction 2.0 I am a soleproprietor or partnership and have no employees working for me in 8, J Remodeling any capacity.INo workers'comp.insurance required.] 9. Demolition 3.0I am a homeowner doing all work myself.[No workers comp.insurance required.Jt 4.01 am a homeowner and will be hiring contractors to conduct all Work ID El Building addition on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I 1.0 Electrical repairs or additions proprietors with no employees. 12.El Plumbing repairs or additions 5.0 lam a general contractor and I have hired the sub-contractors listed on the attached sheet 13.EIRoof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.raOther JJ152,§1(4),and we have no employees.INo 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 thii 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.. Jam an employer that is providing workers'compensation insurance for my employee& Below is the Policy andjob site information. Insurance Company Name: A.4-4iuv.A.I LJi7, 4 ‘c(c Ty.c. Policy*or SeLf-ins.Lic.#: / )/4)C 3 93 -5 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 cer4fjr e and penalties of perjury that the information provided above is true and correct. !+•1,, Signature: t• • •Plan: 411(. 0 ) it 0 6114Y. -1". •Official use only. Do not write in this area,to be completed by city or town official Citpor 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#: ,Z e 94Aze..4.4.a,e4,480;, Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, :„.....,-, --,- ., usetts 02118 Home Improve =ctor Registration ,-,,. ..-7-......_,,-.,..:, -.4..., Type: Individual -:•— .V(.7' MICHAEL III yl..1,,, .:.4i,.-;7,-.;k:, .-,7,7,f.::,-.:t:,7/. RegiStr8d0f1: li393,93 Expiration: 0W15/2021 WEST DENNIS,MA 02670 6. .:.-§',.,,7t. 0.-._:-•:': • 31:i ...A. •:r..•,, -i••• - -:,- -: - ''''''':' "--7.----:-::-.::-...'' ."•;‘--:.' ,:::/,--ti i,,..... .--c-:_-."..i. f..::L.--A:; „i• ,..-. ••••;:,_, -.....---;..- ,:: :- .-1•.:. - • '';:--" .- . .- Update Address and Return Card, SCA 1 0 20405/17 _ ... ... .a= ffAftmmee.mgrie*"...4444aak...40,0 . Office of Consumer Affairs A Business Regulation HOME IMPROVEMENT CONTRACTOR . Registration valid for individual use only Bug=ndNidual before the expiration date. If found return to: Exclrthcn OMM of Consumer Affairs and Business Regidation - 06/15,202j 1000 Washington Street -Suite 710 MICHAEL LK 6 RANGLEY LN. _.1=. SOUTH DENNIS,MI...." -* Not vat out signature Undersecretary .2. commonwealth of Massachusetts BUILDING PERFORMANCE INSTITUTE,INC. Division of Professional Licensure gr Board of Building R ulafrons and Standards 107 Hermes Road.Suite 210 Con r Matta,NY 12020 tr, , , ., 01177)274-1274 CS-058633 I ... -; :,- 1 . !gybes:OW1012041 www.bpi.org ji , . .. , PACHAEL J -.:' '':. .-4' PO BOX 62 ., a i, : ",,,,:i 10.1',7''. .,).).. .. ... ..;. WEST M;'• ,,AA-. • - :," Ir'• ,-, . ., o ...- Michael McCarthz L._t_i :144' '7 BPI 117a:50232 •• . ,..... • , ........ ,•. , Commissioner A.•, e• K. Viemaa-k.. i• . .. (SEE REVERE SIDE FOR DB5NATIONS AND ExPRATIon DATES) Mtbaci McCarthy PC) Box 52 West'Dennis NIA 02670 - . I