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EXPRESS BUILDING PERMIT APPLICATION..., /
TOWN OF YARMOUTH ' RECEIVED
Yarmouth Building Department
1146 Route 28 JUL 08 2022
South Yarmouth,MA 02664
508 398-2231 Ext. 1261
BUILDING DEPARTMENT
By:_
CONSTRUCTION ADDRESS: L .
ASSESSOR'S INFORMATION: 6' /61 g s
i
Map: Parcel:
OWNER: NA ICY o+'';r C()r•p . , '""0$- 77 '-5-S/
NAME • PRESENT ADDRESS TEL. # rt -' 4 g -.6--.
CONTRACTOR:R v c.M c "1 10 6 A r)2:„'v' 9 C 0:2.11 l ✓►6 'iC r P-„:9 3 O X r a-0 36 M 4 v►o)-10 0t H A 02 31-/h
NAME MAILING ADDRESS TEL.#
❑Residential 0 Commercial Est.Cost of Construction$ 2 X 6 7
Home Improvement Contractor Lic.# Construction Supervisor Lie.#C 5 07, h 3 5
Workman's Compensation Insurance: (check one)
0 I am the homeowner )0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent a Duration (Fire Retardant Certificate attached?) Wood Stove [J
Siding: #of Squares Replacement windows:# LI Replacement doors: #
Roofing: #of Squares (®)Remove existing*(max.2 layers) Insulation.
11
l ) ,Old Kings Highway/Historic Dist. Replacing like for like Pool fencing r.
*The debris will be disposed of at:
Location of Facility
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)
rIll be just cause for denial or revocation of my li for prosecution under M.G.L.Ch.268,Section I. I
applicant's Signature: .tee Date: 17'.c`01°°2 2.
)wners Signature(or attachment) ( A 1r 1 r A Date: ��jj 2..
1
approved By: � — Date: /C,9","
Building Official(or d- '• - EMAIL ADDRESS: /
Zoning District:
Historical District: 2 Yes No Flood Plain Zone: 2 Yes ` No
Water Resource Protection District: Within 100 ft.of Wetlands:
^i Yes i No Yes 7, No
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HIC Registration Complaints
Registration 174731
Registrant RICHARD BAKER
Name RICHARD BAKER
Address 18 RAYMOND RD.
City, State PEMBROKE, MA 02359
Zip
Expiration 04/05/2024
Date
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.
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L.N...,,, The Commonwealth of Massachusetts
Department°fin d m sfr la I Accitkna
' ) _I Office of Investigations
Congress Street,Suite 1011
Biøn M4 02114-20 7—
wwkastassgovidia
Workers' Compensation Insurance Affidavi Builders/ContractorsiEleetricians/Plumbers
Applicant information Please Flint Legibly
' , P '•--., I''''...,,, .-
Name(BusinesstOrg"irta-"il: N.c.._ r*-**--"f... .i,---4.7. 4- ,.F 4
---)- ---) ,.-> 1
Are you an employer?.t Check the app`' .him .:.--- 7- i .
-
..i.
1.0 I am a employer with --,, — ..: .,.,
--, ---7 .. .' vevi coustniction
_/employees(full and/or part-dale).* E.4* - , 11
med.az.=samba/street ; 7_ 0 Rouodeling
2.0 I ani a sole proprietor or partaer- 1 1
ship and have no employees Th.= s. 77 Demolition
' Isoodars' '
working for me in any caoack). .64*Yetzm ga"arie 1 0 Buildingaddition
9.
No workers' comp.Mzwe.1...,ze cam - 1;
"--- vt.ert acarrenticte lend& 1.0.0 Electrical repairs or additions
requiredi
3.C3 lam a homeowner doing all work .--FF.,-.ers halve ,..TdIs=-7. .ir. ' 11.0 Plumbing repairs or additions
myself. [No workers comp. ..:-. 11 of ext214/iim per NIGL 1 12.0 Roof repairs
-...nsu_ranee require/1i t .:. 1 4-' 1..f-:f4',_.and ve have no
13.V Other
comp..insurance requised.1 I I 4-..c.:(,:t LIS- c tLi-li 6c's 31'
*Any applicant that checks box I must also flu l on the.w=isca' ..",,w showins thzir w--0.-- '=mpensadon policy information.
f Homeowners who subisit this affidavit Mdizatt .the:, at.ci,::::cg ail work anz!„then he c—•=ide cant actims roust submit a new affidavit indirating sock
1Contractors that check fnis box must eatacbed an elldidocai shent showing the name of the'sub-contractors and state whether or not those entities have
Pmployees. If the sub-cc-mac=have employees,they rust piovide 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.Lie.#: 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 Section 25A of111G1,c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby the'Plit and penalties of perjury that the information provided above is true and correct.
eerta,fra,
Signature: V.... 1,.._..„, Date: ,n, (05-1z''
Phone#: -7 7
I Official use only. Do not write in this area,to be completed by city or town official.
I City or Town: Permit/License#
I Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
IContact Person: Phone#: