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HomeMy WebLinkAboutBLD-23-000710 UNIT B 11 '"Office Use Only -ol4 • O APermit# 0 24.- O . II.,, I. . y C Amount :7 1 CAD ce('1_„* A'„�00�1LL0 Ut$ U' Permit expires 180 days from 7 i c� ;lssue date EXPRESS BUILDING PERMIT APPLICATI( VE G E I VED TOWN OF YARMOUTH Yarmouth Building Department AUG 0 8 2022 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMiENT (508) 398-2231 Ext. 1261 By. ---- - -- CONSTRUCTION ADDRESS: 52 46 ,, 1 ?•(-- Ave.,...-.- , ulaw-7,17- <►2tno.) *I ! O 3 ASSESSOR'S INFORMATION: Map: Parcel: C �,� /71 CS C c. z 7 •-•A) -43�7 r7 OWNER: y G`" (J I b� TEL. # NAME / PRESENT ADDRESS CONTRACTOR, t ti., �ti' 27 / f ' " 4 -1 A-).1 i IN14) - -7i4 -83 "0(5)i S NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction S 4c ..O0 ii)00 Home Improvement Contractor Lie.# 147 �( .Go Construction Supervisor Lic.# 100 `7 2 Workman's Compensation Insurance: eck one) ❑ I am the homeowner am the sole proprietor ❑ 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 1- )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: T F`O rAe. enxi4-ft • nv Location of Facility I declare under penalties of .ury th t the s e nts 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 deni or voca on icense and for prosecution under M.G.L.Ch.268,Section 1. �� Applicant's Signature: Date: 2 1 1�9 Owners Signature(or attachment) Date: E. Od - p1 Approved By: Date: v a .u1 Y�' Building Official(or designee) 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 ❑ No The Commonwealth of Massachusetts ,...R g41,16 ç Department of IndustrialAccidents 1' 1 Congress Street, Suite 100 T W Boston, MA 02114-2017 G "`1v www.mass.gov/dia .4 imp ' .. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Legibly Applicant Information Name (Business/Organization/Individual): ` AY244- /...Address: gq. fq� . � , ?,k n, ©tk/ Phone #: `74' - W r�-�C City/State/ZIp: °/�` F Are you an employer?Check the appropriate box: Type of project(required): 7. New construction 1. I am a employer with employees(full and/or part-time).* — 2. ''''I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity. [No workers'comp.insurance required.] 9. ❑Demolition 3. I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11._Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contactors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.= 14.❑Other 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 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 i Homeownethawho submit this check this box must attached an additional avit indicating they are she t showing the name of the soing all work and then hire nub-contractors and state whetheride contractors must submit a ew or not those entities haveavit indicating ch. Contractors DLit number. employees. If the sub-contractors have employees,they must provide their workers'comp.policy I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.4: City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number by a fine up to expiration $1,5 date). 0.00 Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable and/or one-year imprisonment, as well as civil penalties in the form of a STOP Office WORK In ORDER sRDE anons of the of up tinsurance 00 a day against the violator. A copy of this statement may be forwarded to the coverage verification. I do hereby cer and tl ins and nalties of perjury that the information provided above is true and correct. Date: 8 �?Z Signature: 94 r ' oj3 i c Phone;r: Official use only. Do not write in this area, to be completed by city or town official. Permit/License# City or Town: Inspector Issuing Authority (circle one): City/Town Clerk 4. Electrical Inspector 5.Plumbing e P I.Board of Health 2. Building Department 3. 6. Other Phone#: Cosa Contact Person: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructer Specialty CSSL-100924 expires:09/12/2022 DAVID V SILVA 89 PONTIAC ST HYANNIS MA 02601 °'. p Commissioner d '. btniftia- ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration valid or individual use only Regis_ t`t;n., Exoi___ratio� before the expirat n date. If found return to: 167760 10/26/2022 Office of Consu r Affairs and Business Regulation DAVID SILVA 1000 Washingto D/B/A EAGLE HOME IMPROVEMENT Boston A 021 treet -Suite 710 DAVID SILVA 89 PONTIAC ST HYANNIS,MA 02601 `" !0 Undersecretary Not valid without signature DS11-006048425 neeneeHHa,al Safety .m Health Rdonn:nn;en This and acknowledges that the recipient has socces,Polls completed. 10-hour Construction Safety and Health This card issued to: DAVID SILVA Rony Jabour 43/2018 Trainer Name Date of Issue