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Home My WebLink AboutBLD-22-007332 A Unice Use Only f Of.YRR`7't Permit# s I2,;/g H [� �Amount Jed.00 0 "ATT� " 0`,d'� Permit expires 180 days from x�0p��iCO`� C eb-��-JJJ issue date Bt1 —ate- 641332. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department -- ----- 1146 Route 28 �U� 21 South Yarmouth, MA 02664 2022 508) 398-2231 Ext. 1261 1 BUILDING DEPARTMENT nn -�`� .By: CONSTRUCTION ADDRESS: I if TA-eevi-e-K CA re eke C Y' . ___________ ASSESSOR'S INFORMATION: Map: Parcel: /X re, r— -7, Lc( —z.v3- YOWNER: 1.q 1 I CO . '1 0 6 R e I y -rhea-fee es-y 4), 7C,/-A LI014 / //lift NAME PRESENT ADDRESS r TEL. # Joe King CONTRACTOR: 36 Checkerberry/v4A ADDRESS TEL.# West Yarmouth, MA 02673 Est.Cost of Construction$ C i ❑Residential �� 5b8-775-6448 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Gs- L., -07 It 146 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ' yam 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:# Replacement doors: # 1 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: t.41'+M-(A ti .1-1(7.4 5 ' 6i-ct, 0 4- / ca, a`'.- 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 r ocation of my li nse and for prosecution under M.G.L.Ch.26S,Section 1. Applicant's Signature: Date: ►gnature or a achme daihtefil C.- ivy Date: '— 22----2-2...._ Approved By: it Date: Building Official esi� EiviAl AD SS: w,,,,e ,h,7u,S e ea,h,�f; ete 1,- Zoning District: Historical District: C Yes E No Flood Plain Zone: ❑ Yes E No ei1f 'Water Resource Protection District: Within 100 ft. of Wetlands: Wi 7►"❑ Yes ❑ No ❑ Yes C NoV I1�/ U ' l dtJ "� The Commonwealth of Massachusetts � / Department of Industrial Accidents =fier = 1 Congress Street, Suite 100 -• 4' Boston, MA 02114-2017 a, rs.,.s'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): Joe King Address: 36 Checkerberry Lane City/State/Zip: West Yarmouth, MA 02673 Phone: 508-7 4 Are you an employer?Check the appropriate box: Type of project(required): 1._ I am a employer with employees(full and/or part-time).* 7. _New construction 2. l am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers'comp.insurance required.] _ 9. ._ Demolition 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t l0 E Building addition 4.C 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.E Electrical repairs or additions proprietors with no employees. 12._Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.C Roof repairs These sub-contractors have employees and have workers'comp. insurance.'; 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. �I4. -0ther ea-T to D‘r �' 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 r 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: (i ,it.i Date: --Tidy/e- 2 I- Phone#: Sd cr—f) 1 c -6 cf ce t- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License r Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: .K - c • • 0 E NTo a i 0 O az C�� J < I I r I 1 w .1. 7 W p J � �g °�isrorvt��, _ co,,, ti co ai m 1-� - .„ = 't a E* ne, ,->r, r 2 --6 (13 .':j, 0. _. .,,: :..yil:, ,:, . .$,.. ,._ . = . .44...- e, ..) , 0 •,, . , - ;1 -.,48,4, = Uttitintt -, ),-: ' CU'eX N A .1.14 U'_c r;W' OJ ..,•..,i'i °,,. -.• e It1J'iI ' m. Z Q 4. w U Q 1 2 CO o o O Ulm m ` w o Q ��1-" ,-..!::.-:.':,,•',.-,-.-,4i,..t).---.i-'..fi -,-i,.::I..l,.,. l•i--,•y:,A-, 2 N ' • .,,'..,, : :' e01 !,:.i.-:,;.,...w..1,.- pQ 0 m 30Ig . 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