HomeMy WebLinkAboutBLD-23-000944 pF.'YRR °j � /0 Office Use Only
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RECEIVED
�JJ' 1: !' C Permit# )
� M ri ln'sc 'x AUG 1 " 2022 Amount SD
°*ra no/
Permit expires 180 days from
BUILDING DEPARTMENT issue date
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 9 Thora Ln
ASSESSOR'S INFORMATION:
Map: 118 Parcel: 66
OWNER: James Driscoll 9 Thora Ln 508 766 2166
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Troy Walls 87 Cranberry Ln S Yarmoutl 508 394 1205
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial 12000
Est.Cost of Construction$
Home Improvement Contractor Lic.#105179 Construction Supervisor Lic.#044847
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor 9 I have Worker's Compensation Insurance
Insurance Company Name: Aim Mutual Worker's Comp.Policy#WCC-500 5009587-11/22
WORK TO BE PERFORMED
Tent Li Duration (Fire Retardant Certificate attached?) Wood Stove I I
Siding: #of Squares 9 Replacement windows: # Replacement doors: #
Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation l l
I-Xl
Old Kings Highway/Historic Dist. IQ Replacing like for like Pool fencing I I
OIL Ll► it f1K )► 1U LcclO's , 444.4v‘ t'/ )y)?
*The debris will be disposed of at: Yarmouth Disposal Area
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 orjoa,on of ense and for prosecution under M.G.L.Ch.268,Section I. p Applicant's Signature: � 8/12/22
Date:
Owners Signature(o chm tM) ,,� ,
"� 1�-'�t , Date:8/12/22
Approved By: �L
Building Official(or d ee Date:
) . EMAIL ADDR S
Zoning District:
I-iistorical District: :%, Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft of Wetlands:
Yes No Yes No
. The Commonwealth of Massachusetts
=+w, _ Department of Industrial Accidents
;111
rr = 1 Congress Street, Suite 100
.\_af� Boston, MA 02114-2017
v 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): Walls Construction
Address: 87 Cranberry Ln
City/State/Zip:S Yarmouth, MA 02664 phone #: 508 394 1205
Are you an employer?Check the appropriate box:
Type of project(required):
l.❑✓ I am a employer with 1 employees(full and/or part-time).*
7. ❑New construction
2.0I am a sole proprietor or partnership and have no employees working for me in 8. ®✓ Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work myself. t 9. ❑Demolition
❑ y [No workers'comp.insurance required.]
40I am a homeowner and will be hiring contractors to conduct all work on my property. 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.❑Plumbing repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
60we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(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: Aim Mutual
Policy#or Self ins.Lic.#: WCC 500 5009587-11/22 Expiration Date: 11/22
Job Site Address:9 Thora Ln Y ort MA 02675
City/State/Zip: P '
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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 8/12/22
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constri.ot ,4 14'$,rvisor
CS-044847 spires:07/05/2023
TROY A WALLS ;`.
87 CRANBERRY LANE `"
SOUTH YARMOUTH MA '02664
b
Commissioner dada i. b&mckca.,
Q_FZ- Fo/n/no-/mo-ecaf‘.1 6"/4eze)editaieic.ie/41-
Office of Consumer Affairs and Business Regulation
1000 Washington Street o Suite 710
Boston, Massachusetts 02118
Home Improveme'rit�C'Ontractor Registration
Type: Individual
; Registration: 1059TROY WALLS 3 7if ,
87 CRANBERRY LANE ; } ,; ( Expiration; 07/15/2022
SOUTH YARMOUTH, MA 02664 I it '
f.1 i;1
//
A I t} 20M.05/17
Update Address and Return Card.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TY,.pE:Individual before the expiration date. If found return to:
RegistY�atlon Expiration
g9�179 0xi:agn Office of Consumer Affairs and Business Regulation
1 „ 1000 Washin t -Suite 710
TROY WALLS 1, 11
:)1,:...,_� �,, Boston 02118
TROY A,
87 CRANBERRY tAr ; ;%; „'
SOUTH YARMOUTH -'02664 �i����aGGf�i
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