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Home My WebLink AboutBLD-23-000883 Office Use Only RECEIVED p Yq� �t# c .� v,s G -_. _._ . . U .0.)-.fit,- x. AuG 14Amount Permit expires 180 days from!ISZe****1; ` issue dafe BUILDING DEPARTMENT By __---- C C.P EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 3 6 B tzews7- x--RD - 14i, A,ill 0,--)A /116 .. CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: IMap: I Parcel: i 1/1 / / /j o,' 36 /-/igH ,5-:�; / ��f4413-°e- 33-1--5 91', OWNER: I PRESENT ADDRESS 0 93 r( TEL. # NAMEn J ) Yar c— ✓CONTRACTOR: 1�.AQl rI Ps ,�=/i/aGIrG 3 ( d/�B)5'� ni a'v`dived 3-a I7 7 6—/ 3 NAME MAILING 0)ii Commercial Est.Cost of Construction$ ,.,�j O CO-C C) Residential �g ('� Home Improvement Contractor Lic.# 7/L/ /--7/g Construction Supervisor Lic.# r$ O V ✓= 3 7 Workman's Compensation Insurance: (check one) 0 I am the homeowner A I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Cl Duration (Fire Retardant Certificate attached?) Wood Stove P Siding: #of Squares Replacement windows:# Replacement doors: # 1 Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation n I I Old Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing_ *The debris will be disposed of at: �Gi KJ/1 d IX,'/l JJ/S )O 3a / Ac f 1 ify Location ofcility 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 revoc 'on of my license and for prosecution under M.G.L.Ch.268,Section 1. -� -7 , f J Date: F / ,,2 Applicant's Signature: 1�f �Z ' / ' (.{ D / /!�l/ .� U.� Date: ///o�v�. Owners Signature(or attachment) / �f� 'r�� '` "`L r/ ` ./ Date: v Approved By: 40 Building Official(or d „i MAIL ADORES Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: D Yes ❑ No 0 Yes 0 No The Commonwealth of Massachusetts y Department of Industrial Accidents __` '= .1 Congress Street,Suite I00 iIc 'y Boston, MA 02114-2017 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): L 1 Gl r/ e3 /2/j�a Li to Address: 20 3 O p / op 5 I- City/State/Zip: Y 0 t f v / 101 Phone#: 7 7 / 6_ 3 employer?Check the appropriate box Are you an ployType of project(required): 1.01 am a employer with employees(full and/or part-time).* 7. (]New construction am a sole proprietor or partnership and have no employees working for me in 8. Remodeling capacity.[No workers'comp.insurance required.] 9. Demolition 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t 10['Building addition 401 am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.[�Electric�l repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.['Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurances / 14.1i?Other rer 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 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. tr..uulata.lusb that check this box must attached an additional sheet showing the name of the and state whether or not those entities have employees. If the sub-contracaas have employees,they must provide their workers'comp.policy number. I am an employer that is prov ding 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: 3 9 Or p 64./5 7 t i kcir City/State/Zip: 14/, 1/4/in 0/AA 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 ofp+�r'that the information provided above is true and correct f Signature: � ' 7/17( / Date: Phone#: car - 7 ‘ /2 3 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): 5.plumbing Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 6.Other Phone#• Contact Person• • • • g Or fret tff4fEt'kAWA sATA61€84 non HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: e i tion Expiration Office of Consumer Affairs and Business Regulation 1 , 10/18/2023 1000 Washington Street -Suite 710 CHARLES J. Boston,MA 02118 H 1 .. CHARLES J ae:2„/„..,203 UNION S YARMOUTHP rAWO 75 Undersecretary Not valid w out sig ure Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons lan'kialfarrisor • CS-042539 w re Tres 06/10/2024 CHARLES JNIA 203 UNION S t YARMOUTH• Commissioner daia t;, „r}r� •