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Home My WebLink AboutBLD-23-002990 Og•Y4 Co' '.Office Use Only ' ei.Ph '1, HOC I,)-'�/ /Z, Permit# • t J { pph �, 1 ;Amount 3-4,vV M,::ia, CSC ,"°""°`°gyp �� j Permit expires 180 days from c l issue date 01,1)-02.3.66? EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664/p DEC 01 ZaZ2 � (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: `,° CC ��s-r Cr— , BUILDING DEPARTMENT By: ASSESSOR'S INFORMATION: Map: Parcel: OWNER:,i( 7 LI 32. 2-1 3 37 NAME PRESENT ADDRESS TEL. # CONTRACTOR:M- 1'lYha—._ t 6)C p)\.A f S L- S-b g - 3 e.Li --c ) Z_._ NAME MAILING ADDRESS TEL.# Ly.ITesidential 0 Commercial Est.Cost of Construction$ I ) / b co . crb Home Improvement Contractor Lic.# k‘-3-1 `1 di Z Construction Supervisor Lic.# 10 5-01 I g Workman's Compensation Insurance: (ck one) 0 I am the homeowner FYI am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: # of Squares Replacement/ windows:# Replacement doors: # Roofing: #of Squares -2--c _ ( V)Remove existing* (max.2 layers) Insulation XOld Kings Highway/Historic Dist. x)Replacing like for like Pool fencing 1(�l?ct. w - d �^ " h . 4-1 oil/a *The debris will be disposed of at: I (\ 1 ' US C Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sib a -. I We' Date: 12 � c7 / (/ - '12 — - Owners Sig. ature(or att. en �jyw Date: I �` / Z�/ Z -L....Approved By: "Ngvi Date: i L /�Z Buildinv! .P•. 40%1..-- EMAIL ADDRESS: Zoning District: Historical District: 0 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 oflndustrialAccidents 1 Congress Street, Suite 100 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 Lecribly Name (Business/Organization/Individual): r a_k).) ` J — Address: } O G f (1.e 7S C— ( ) & City/State/Zip: 02-6 3 6 Phone #: S 3 G 2--- 9 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. Ej New construction 2. I 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 3.01 am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 Q Building addition 4.0I 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.Q 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. c[ oof 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.❑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: 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 violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct `3 2-t 22_ Signature: Date: 1 CS Phone#: 6� e - 6..L1 - c 29' 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#: Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Const atAg > isor tP CS-105918 ., Eicpires:09/15/2024 MOHHMED 8 RAHMAN • sa 70 OLD PHINNEYS LN C BARNSTABLt MA 02630 • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 173492 10/08/2024 MOHHMED RAHMAN D/B/A ALL CAPE BUILDERS MOHHMED RAHMAN 70 OLD PHINNEYS LN ;,, tei' fijf,/. BARNSTABLE, MA 02630 Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, MA 02118 Not valid without signature Sswwww- .. CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO-RIGHTS UPON THE CERTIFICATE R:THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENS, EXTEND OR ALTER THE COVERAGE AFFORDED DED THE ES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT orrwietw THE ISSUING IN WR fS}. AUTHORD20 REPAC.IENTATTve OR PROD;C R,AND tTae Cart nre-ATE hfOLOEit IMPORTANT: If the trstiflcate hohist Is an ADOITX)NAL INSURED,the pottcytfiss)must have AOOITIONAL INSURED j sIsIoes of Ire ssfforPFIFT tf SUBROGATION IS WAIVED,subject to the term and conditions of five policy,cartith policies may rapture ere ertdr,,rseptert A state/sem ref thre earthaste Bops not confer is to the cent/karts holder in lieu M such* a Ts:Na Sow 607,37 Pate Alto,CA SANDE supporprepapanurapcs,cor �.,�. AMNIA A Stilt NBtlonAl Ittsaarance C /R 2.V:I to ?.tram ra+rrt I All cast tooiders 70Otd t'Pt yz In BdtrstariV,MA02. t6itxF.Rt: COVERAGES CERTIFICATE NUMBER:631373a REVISION NUMBER, THIS Is To CERTIFY THAT THE POl iCIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POMCY PERIOD SI53I..A':`t:»U NOTWITKSTAIi{J$+tfia ANY REOUIS'iE4IVENT,TERN OR<1:3NDITION OF ANT CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TIPS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS: CXC LIStO tS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. opt,kirthLIA TYm6CEotsLma,K5 i. ocx,rcwavl,?eex l r'f'"S Y}+XI LAMS X fi IAL Se#CxAL LiArxu rt € 7 + S1 tIGtXI d C3;AN&MA0. * ' t`L =t�`i ? #e" A .„.a.. - LETIMM tE S SST Fw "11 143_ SXE £XP. rritg9t'l3gt Y1"ICale0 . .4XTYI iN fSAi"^Da(`it �'lY,l/ ?22 °LT i'T2fc'41Z3 .B RrtV tPi.tllrlY ;AS 3 7p'"K> c a fi a F mA^k t€ku A% k FED a 0.ENE A. ;'iihCt}ATE $2,000 00O PR9DIC.:TS $a?RSFVFA,ada $2 009W,,. i-At LLaa irY C 3LEL14PI LISAW L ALIAR C:ouR EACi WRSENCE $ffX" S IAB jI I ANY AUTO !. I ; , 'DEC ' ,.R:ErENT.NS p * A.W.^ERI'RLL^YER3'kak4,+a.ITY I'.N �uTT g. OCR tot hall ,_.,.. ,Igavlaaey .. {Tg'.� gd %CYaz'."T.A',d?hR'a w41t.*nr I:.�.:A""! 6�S3C.' ° ,.,.. ._w-. pm ,. q r Ira tors 1 s s artd Clmis o^,s ,EsII urrrncs; $25,0 ,XIYHl!1`SAE o2-Gi. 02,12/2022 32.12;2023 i €-tasc-.upTioN or INIERATIOAA$r LOCATIONS t YeiICL,ES rACORD ICI,A#@fYunel Remarks Stha9Jk,may be ell eel If wee soap IA+putvy4,11 #}jY 1 1 ray fCE TIFtCATE HOLDER CANCELLATION - --/ — ,�,.., ' , SHOULD ANY OF IRE ABOVE DERIBEDPOUCtES BE CANCEt.LEo BEFOR -L.P. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I ACCORDANCE MTH THE POLICY PROVISIONS, t AbTH€P{ZC. ttf..PltE'i.'IIE'ATF1+'C ""•..„.. ` ,..�....... _ •1988-201S ACORD C(3 POP T— AiQ rights1 ACORD 2512G16,12 The ACORD name and eosarw d. logo are registered marks:of ACORD