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Home My WebLink AboutBLD-23-001903 Poi )6HzI Z r Office Use Only .`'. A Permit# ail sZ 0 1a5—`OL ��"' ;Amount O\,.p 1A*,...t.r.v.ous4,n')_, ts*7 ,,,..0Permit expires 180 days from issue date 6&D-,923-DOr4*3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 OCT 11 2022 i (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 109 pond street South yarmouth, Ma 02673 By ASSESSOR'S INFORMATION: li Map: Parcel: OWNER: David Stewart NAME PRESENT ADDRESS TEL. # CONTRACTOR: Griffin Custom g 18 Flicker Lane W. Yarmoll 774-212-0554 NAME MAILING ADDRESS TEL.# 0 Residential 0 Commercial Est.Cost of Construction S 15000 Home Improvement Contractor Lie.#195621 Construction Supervisor Lic.#113663 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor El I have Worker's Compensation Insurance Insurance Company Name: Ace American Worker's Comp.Policy#6S62UB6R02586A22 WORK TO BE PERFORMED Tent Duration 1 (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 3 Replacement windows:#4 Replacement doors: #1 Roofing: #of Squares 15 (2)Remove existing*(max.2 layers) Insulation L I I I Old Kings Highway/Historic Dist. (Q)Replacing like for like Pool fencing *The debris will be disposed of at: Yarmouth dump Location of Facility I declare under penalties of perj that the statem> 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 ca' o y q.e: a for prosecution under M.G.L.Ch.268,Section 1. r Applicant's Signature; Date: 1 0/1 0/22 Owners Signature(or atta lent) ` .�:'0 Dare. 10/10/22 1 Approved By: Date: 7,7 /-2_- 2.2_ Building Official(or designee) All,ADDRESS: Zoning District: Historical District: i.. Yes ::? No Flood Plain Zone: : Yes _: No Water Resource Protection District: Within 100 ft.of Wetlands: C:,i Yes No Yes No Commonwealth of Massachusetts Division of Professipnai Licensure Board of Building Re ulations and Standards Constii E't i isor CS-113663 t spires: 12/23/2022 JARED J GRIFFIN. f 18 FLICKER LAN WEST YARMOIITI' 3 0 ¢ t Commissioner• THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff E Business Regulation HOME IMPROVEMEADPONTRACTOR TYPadualIitain JARED GRIFFIN 1 ; t L ,t'Il/f612073 D/B/A JARED J.GRIf 1-' -'t 1 JARED J.GRIFFINer 18 FLICKER LANE �, :, WEST YARMOUTH,MA ��`` a 'CG•� • Undersecretary ==\ The Commonwealth of Massachusetts = Department of Industrial Accidents el'= 1 Congress Street, Suite 100 _ .= Boston, MA 02114-2017 .:.F' www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Griffin Custom Builders Inc. Address: 18 Flicker Lane City/State/Zip:West Yarmouth, MA 02673 Phone#: 774-212-0554 Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with employees(full and/or part-time).* 2.0I am a sole proprietor or partnership and have no employees working for me in 8. ❑Rem delinruction any capacity.[No workers'comp.insurance required.] 8• 0Remodeling 3•0i am a homeowner doing all work myself.[No workers'comp_insurance required.]t 9. ❑Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees. I I.QElectrical repairs or additions 5.1DI am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.ElWe 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.] t*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 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 viol. .r.A copy of this tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifica '4 I do hereby cer '.' 1 4 er the I gins and nalties of perjury that the information provided above is true and correct Signature: 10/10/22 Date: Phone#: 77' 12-0554 Official us• 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#: