HomeMy WebLinkAboutBLD-23-001498 -i-Y,qR . e.o/l e+A- Office Use Only
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EXPRESS BUILDING PERMIT APPLICATIO R E C E I V E
TOWN OF YARMOUTH
Yarmouth Building Department r SEP 2 0 2022
1146 Route 28
South Yarmouth, MA 02664 BUILDING DEPARTMENT
(508) 398-2231 Ext. 1261 By:_
CONSTRUCTION ADDRESS: C a Vc _ V f e_ f p(—I ti7p..r 01747 MA
ASSESSOR'S INFORMATION:
I
Map: Parcel: F
✓OWNER: c Ph.,1 1 A , S C nJ A 1 C-t)l/t Vr,2 b✓ 0 r -7 6O 1
NAME PRESENT ADDRESS TEL. #
✓CONTRACTOR: l I Tip !/L ( .S C 7✓ 1 // I i T:) T O 3I 2--,
NAME MAILINGADDRESS TEL.#
IGRI
idential ❑Commercial Est.Cost of Construction$' Nt,..t.--a)
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Home Improvement Contractor Lic.# /(i> <7 C> 7 Construction Supervisor Lic.# t)9., / a.,,1
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ I am the sole proprietor ' I have Worker's Compensation Insurance
Insurance Company Name: -s A—y lJ' 114r's Comp.Policy# SO 0 Sb 27N 7 7 7
o r1/'5 M u \rle-1 "-M 5 L v
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replaceme windows:# Replacement doors: #
Roofing: #of Squares ( ( emove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: ( i/tA. ? I A.A) 1 )
Location of Facility
I declare under penalties of perjury that statement erein contained are true and correct to th • f. I understand that any false answer(s)
will be just cause for denial or revo ton of my li se and for .Ch.268,Section 1.
✓pplicant's Signature: , D Date: f j� /e ___•*"--2.—
✓ )Owners Signature(or attachment \ c Date: [ Jicl..
Approved By: Date: 7-- -3
Building Official(or desig EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft. of Wetlands:
0 Yes 0 No 0 Yes 0 No
'\ The Commonwealth of Massachusetts
+ �_ Department of Industrial Accidents
=��1� 1 Congress Street, Suite 100
•_aF_ 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):---irs.A 4 l f-C�
Address:3 O SC_c) , �I` ,,c),),,
(I QI
City/State/Zip:W f.,/S-- - IA), 44A_ Phone #: ;cow 97 y rf,3 /
Are you employer?Check the appropriate box:
Type of project(required):
1. I am a employer with(f employees(full and/or part-time).* 7. _ New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. C Remodeling
any capacity. [No workers'comp. insurance required.]
3. I am a homeowner doing all work myself. 9. ❑ Demolition
❑ y [No workers'comp. insurance required.]`
4.❑ myProPertY•I am a homeowner and will be hiring contractors to conduct all work on I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.[ Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof 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. 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-contracto s 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.r, t 4- ,�S-r-r^ ,M ,ii C.2,
Policy#or Self-ins.Lic. #: bO. t7 ra....3 Z7 7 Expiration Date: ? 9-4(, 'moo ,
Job Site Address: � Loy, \7 City/State/Zip: A-1/44d L o i /
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requ' ed under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, a ell 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 f this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cer ' and t1 epains andpenalties of perjury that the information provided above is true and correct.
Signatu
Date:
Phone : . -7 L( 01 /'-1
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Commonwealth of Massachusetts
Igr Division of Occupational Licensure
Board of Building Regulations and Standards
Constructl� e
UPEr Specialty
CSSL-099828
x pires•06/01/2024
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HIC Registration Complaints
Registration 165907
Registrant THEODORE HITCHCOCK
DBA TL HITCHCOCK CONSTRUCTION
Name THEODORE HITCHCOCK
Address 2 Quinns Way
City, State Mashpee, MA 02649
Zip
Expiration 03/09/2023
Date
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.