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Home My WebLink AboutBLD-23-002291 e it I)'c1 f t)Lqi g2 Office Use Only OF• * ` '. Permit# M.c3 ,fl .' ty )y, j/1 i Amount �es t"' NATT M bR� d Permit expires I$O daysfrom issue date fit- P -a3- 6d -9/ EXPRESS BUILDING PERMIT APPLICATII TOWN OF YARMOUTH R itCEiVED Yarmouth Building Department 1146 Route 28 OCT 27 2022 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By CONSTRUCTION ADDRESS: 18 Brewster RD ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Allison Ron Cedilla c 18 Brewster Rd 508-776-2979 NAME PRESENT ADDRESS TEL. # CONTRACTOR: David Collins 20 Piccadilly Rd Sandwich 508-245-0249 NAME MAILING ADDRESS TEL.# El Residential 0 Commercial Est.Cost of Construction$1,500.00 Home Improvement Contractor Lie.#128799 Construction Supervisor Lie.#cs-073547 Workman's Compensation Insurance: (check one) 0 I am the homeowner Err am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent LI Duration (Fire Retardant Certificate attached?) Wood Stove L__l Siding: #of Squares Replacement windows:#3 Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I l I I Old Kings Highway/Historic Dist. a)Replacing like for like Pool fencing *The debris will be disposed of at: Bourne Dump Location of Facility I declare under penalties of perjury that the statements��ttt herein contained are true and correct to the best of my knowledge and belief I understand that any false answers) will be just cause for denial or revoca of my lic{tse and fo' rosecution under M.G.L.Ch.268,Section I. Applicant's Signature: at,r ' Date: /6 -?£ "D.) Owners Signature(or attachment) x/ &Of/ vof e-f t 1 Date: J _ /'f._ , Approved By: �✓ Date: f,L �e Building Offici r d ee) EMAIL ADD Zoning District: Historical District: Yes I No Flood Plain Zone: . Yes C_ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes i No "! Yes i No The Commonwealth ofMassachusetts t 4 setts aj Department of Industrial Accidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 ., wwN.mass.aov/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): David Collins Address: 20 Piccadilly RD City/State/Zip:Sandwich Mass 02563 phone #: 508-245-0249 Are you an employer?Check the appropriate box: Type of project(required): l.pI am a employer with employees(full and/or part-time).* 7. ®New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'camp.insurance required.] 8. �✓ Remodeling 3.pI am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on 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. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet i2'®Plumbing repairs or additions These sub-contractors have employees and have workers'camp.insurance.t 13•❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.D 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. ''Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must atrarhed 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.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 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 certi under t e airs and penalties of perjury that the information provided above is true and correct. Signature:�n ture: Date: —(22 < Phone#: Cls- y 5 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): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: i A 1 ! 1 N tea* X , J N; i1t rrz :.� tp d co � z N cU - a,wO O � . r &U N C AJ M Z<, 111 f.) 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