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Home My WebLink AboutBLD-23-001667 .,. ;Y^ Office Use Only r« ,., \p•. RECEIVED Permit# O ." �+'1!,„ /*3' Amount `k ' MA to M (,F!„ SEP 2 8 2022 - 4 �`°�4 c' Permit expires 180 days from � T�Yd'I J � issue date B U I ejf�.� 9 , j�/�,ci"23— EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 f CONSTRUCTION ADDR SS: �� T ��' " Pr /fn 0 ("IA ASSESSOR'S INFORMATION: Map: Parcel: r f OWNER:�60 ,44a//I QIvo.s g 1-E= s'�,,hece- 367''- l 9--366 9 AME PRESS �JDDRESS TEL. # CONTRACTOR:3 t2 1611 -3 b :5--14 diNedht 6z. w —2 (---9 9 6 NAME MAILING ADDRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ 0®®et Home Improvement Contractor Lic.# f Oal '0 0' Construction Supervisor Lic.# 05-/0 5 06 Workman's Compensation Insurance: ( ck one) 0 1 am the homeowner am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name:`/ere-lu., Worker's Comp.Policy# WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares (0)Remove existing* (max.2 layers) Insulation El El .Old Kings Highway/Historic Dist. Replacing like for like Pool fencing i l *The debris will be disposed of at: X,/ne`l// /lft2 N" Zvic� Location of Facility / I declare under penalties of perjury • t the statements herein contained are true and correct to the best of my knowledge and belief 1 understand that any false answer(s) will be just cause for denial or re ion of my licen ' I d//secution under M.G.L.Ch.268,Section 1. i 7-.2Q2 Applicant's Signature: / _ 7 " 7). Dater Owners Signature(or attachment) -af,liz Dater A roved B : .e. ' � Date: 0 pP Y / Building Official es. EMAIL ADDRESS: .J Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 1.13 -z Boston, MA 02114-2017 SY•yr www mass.govfdia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TJIE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): l/ ! �K// 643Acosika q,n Address: 7 S X&x City/State/Zip:it/ziwetd/A, d 7 3 Phone #: C�� = -- 4//" 9�! Are you an employer?Check the appropriate box: Type of project(required): 1.01 a. a employer with employees(full and/or part-time).* 7. ❑New construction 2.11 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'camp.insurance required.] 3.DI am a homeowner doingall work myself. t g• ❑Demolition ❑ y [No workers'comp.insurance required.] I am a homeowner and will be contractors to conduct all work on my10❑Building addition 4. ❑ hiring 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.QPlumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. j; El Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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: �C�'LC`t l V€- I) S,„ Policy#or Self-ins.Lic.#: 7 Expiration Date: /—1 2c Z�� Job Site Address: 9 L i't7`LE? 'p peT to iv e City/State/Zip: 14vTI ,41 ,Da 669 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 cerLunder the pains and ,entities of perjury that the information provided above is true and correct. Signature: Date: —c2 Phone#: `� �` / ?.6y 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#: fi'. `- THE COMMONWEALTH OF MASSACHUSETTS ry Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 186088 09/27/2024 ' BARRY HALL a D/B/A CREATIVE CARPENTRY z.,,' BARRY HALL 3 BETTY'S PATH ,/,,,, r W. YARMOUTH, MA 02673 Undersecretary , 4 Commonwealth of Massachusetts `P Division of Occupational Licensure Board of Building Regulations and Standards Regulations � r s r ` Cons > CS-105506 pires: 12/3112023 BARRY R HAj.L 3 BETTY'S PATH �' , WEST YARMOjJTH MA 02673 $ `,T. . Commissioner dam. 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