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EXPRESS BUILDING PERT API'LICATRRiC E 1 V E D
TOWN OF YARMOUTH Yee
Yarmouth Building Department AUG 15 2023
1146 Route 28 South Yarmouth,MA 02664 B U I L D I N G DE PARTM E NT
By:
(508)398-2231 Ext. 1261 ______
CONSTRUCTION ADDRESS: 36 Dancing Brook Road
ASSESSOR'S INFORMATION: Map: 58 Parcel; 154
Maurice Hennebr� 186 Driftwood Lane, Trumb jf l Of 508-394-0194
OWNER: Maurice
ADDRESS TEL.
�� 774-212-0938
CONTRACTOR: C A. Vincent, In. 17 Still Brook Road, South Yet; #
NAME MAILING ADDRESS
Est .2.Cost of Construction$ — i -�7
O Residential ❑Commercial 095633
Home Improvement Contractor Lie.#
182000 Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Worker's Comp..Policy#
Insurance Company Name:
WORKTO BE PERFORMED n
(Fire Retardant Certificate attached?) Wood Stove LJ
Tent. Duration �
Siding: #of Squares 1,3 . _. Replacement windows:# —
Replacement doors: #
Roofing: #of Squares (❑)Remove existing*(max.2 layers)
Insulation
__IIIL Old Kings Highway/Historic Dist. (Di Replacing like for like
Pool fencin
M. A. Frazier
*The debris will be disposed of at: Location of Facility
declare under penalties of perjury that the statements herein contained are true and correct
to the
best of my Section 1,
knowledge and belief. I understand that any false answer(s)
I
will be just cause for denial or revocation of rn license and for prosecution under 8/15/23
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Date:
Applicant's Signature: w..!.L, Date: 8/15/23
Owners Signature(or attachment) � j
�..Al A gate:
Approved By: r i �ee EMAIL . r:ti SS:
Building Office )
Zoning District:
Historical District: Li Yes '. No Flood Plain Zone: ! Yes 3 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes Ll No 3 Yes 3 No
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$6040414
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The Commonwealth of Massachusetts
Department of Industrial Accidents
:i:- 1 Congress Street, Suite 100
Boston, MA 02114-2017
—tom 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): C. A. Vincent, Inc.
Address: 17 Still Brook Road
City/State/Zip:South Yarmouth, MA 02664 phone#: 774-212-0938
Are you an employer?Check the appropriate box: Type of project(required):
1.0I am a employer with employees(full and/or part-time).* 7. ®New construction
2.0I 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
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4.0 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.❑Electrical repairs or additions
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.ID Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑✓We are a corporation and its officers have exercised their right of exemption per MGL c.
14.E Other re-siding
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#or Self-ins.Lie.#: 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 certi;fy under the pains and penal ' of perjury that the information provided above is true and correct.
Signature: Date: 8/15/23
Phone#: 774-212-0938
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):
I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: