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Home My WebLink AboutBLD-23-002258 4/l 4-0=PIPeda6essaw$l_robe fold s,6HMi08xXS0NAPIANIN IZ(IPPwPAIbiHMlXQ3)i/X0(144#/0/n/Ilew/uoo 9160061!ew//ad114 lb)2-7182 1 Office Use Only .$'e. a 1 Permits �i (7 2 r/ wI Amotmt r/1 Z'0C ' � �:w4°rS 1 Permit expires ISO days from issue date EXPRESS BUILDING PERMIT APPLICATION -a 3 - ZZ TOWN OF YARMOUTH Yarmouth Building Department - RECEIVED 1146 Route 28 South Yarmouth,MA 02664 (508)398 2231 Ext 1261 OCT 26 2022 CONSTRUCTION ADDRESS: 31 Tay-- (cA. ....1I fl._____.__ R(,Jlir•Ir; (-?APARTMENT By._ ASSESSOR'S INFORMATION: — -- I Map: I Parcel: I OWNER: To nM Ar*Ulf 31 To- ('& 4/l 3- ti?8- o a8 1 NAME PRESENT ADDRESS TEL. # CONTRACTOR: n jo at r40.1'1o" Mg, tO %jayc 1a5 " ahms M6v1 Cs 5o P-360-to 13 - NAME MAILING ADDRESS TEL N t7 Residential ❑Commercial Est.Cost of Construction S 3 coo 1 Home Improvement Contractor Lie..# 171'(CO Construction Supervisor Lie.# 1127 tin-7 Workman's Compensation Insurance:iicheck one) El I am the homeowner sn am the sole proprietor Cl I have Worker's Compensation Insutarn.e Insurance Company Name: Worker's Comp.PolicyF WORK TO BE PERFORMED (� Tent II Duration (Fire Retardant Certificate attached?) Wood Stove t i Siding: #of Squares t'{ Replacement windows:# Replacement doors: # Roofing: #of Squares ([J)Remove existing*(max.2 layers) Insulation El fi 1 I Old Kings Highway/Historic Dist. p Replacing like for like Pool fencing E *The debris will be disposed of at )1a 4.0 tan‹.-i-a- Location of Facility I declare under penalties of perjury that the statemen "n contained are true and correct to the best of my t-nowlcdgc and belief. I understand that any false answer(s) will be just cause for denial or f my " and for prosecution under M.G.L.Ch.26S,Section 1.Applicant's Sitrature: Date: /)141i!1 o' Owners Signature(or attachment) Date:Date: t e ��l! Approved By. 2 2 Building OM- ) EMAIL S: /r p i�tgeC,-.wan 1 .L --.. Zoning m r� /'�J�L / Historical District: . Yes it No Flood Plain Zone: _ Yes No ti Water Resource Protection District Within 100 ft.of Wetlands: Yes V No `: Yes V No odP'179loNvOS Pld 9Z:L£'ZZ/17Z/04 The Commonwealth of Massachusetts Department of Industrial Accidents ==oI 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass aov/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): �cc'i1dr) 130y(,ems Address: 6 71 (J-)& ` y QA City/State/Zip: A .1,r,S /v1,4 0.(q .f > Phone#: 508-36 0 13 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. � ew construction 2. 'a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp_insurance required.]t 10 Q Building addition 4.0I am a homeowner and wiI be hiring contractors to conduct all work on my property. I will ensure that an 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.Q Roof 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.Q 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. 1.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.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 a 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. £do hereby certify under the ins and penalties of perjury that the information provided above is true and correct Signature: Date: /O/a X.4/a Phone#: 61 g 5(V k 13 a- Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 0 Office of Consumer Affairs&Business Regulation I ' HOME IMPROVEMENT CONTRACTOR i TYPE:Individual Reg istr, t$of Expiration 179414 01/13/2023 NATHAN BAILEY) 1 NATHAN BAILEY'w� / / 679 WAKEBY RO% „ f !u ga f' ` BARNSTABLE,MA O2848'''' Undersecretary f Commonwealth of Massachusetts N1 Division of Professional Licensure . Board of Building Regulations and Standards Cons r tt itiiprvisor • !i CS-107447 ' :. y 1piras:08/30/2023 NATHAN BA$''EY -a 679 WAKES n s MARSTONs� , O 'F ,L }0>SS�a , I r • Commissioner d,it K. ern ta.. , i • 7.