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Home My WebLink AboutBLD-23-003399 1 • co:yRR CUM. )Cep W I(1G_ pay i J pliv '�Office Use Only : '. ,} �70 Permit# e a y )u Iz121 )32- (/1 ,'Amount (/ ` MATTACM ESE d j,SZ . %-)0 xw....E0.-E� I Permit expires 180 days from i issue date BLD - L3-6a33gf EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 DEC 19 2422 1- (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7 4t/.itTe.. / 415?ir ZIA BUILDING DEPARTMENT B y- ---- ASSESSOR'S INFORMATION: "" �'' Map: �7 Parcel: 7 y' !�' /� OWNER: `�✓ (-1, "J cdA,�S f a 1.iii,7 . / �1. 1&.J ✓t4Ii( O2l NAME7 �SEADDRESS TEL. # CONTRACTOR: ,47AM' A 346X;(7446 ale ✓ " ` Li, „1j0. -s—a- 774 . / / NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ r 'Y,. o Home Improvement Contractor Lic.# /.?1 71 Construction Supervisor Lic.# 099(n9 Workman's Compensation Insurance: sc,Aeck one) ❑ I am the homeowner 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 70 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: "° s . _)\co ✓°'" i 'J 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 Signature: 'AJAt-id 3U',1�.-/ 1(- f 1t Date: 02-/r 7AZ.- f Owners Signature(or attachment) U f , , -,,_• Date: J2 / 1) BuildingOffi ' (or ignee EMAI .,�� / Approved By: Date: / � �— �• SS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents _v I.1' 1 Congress Street, Suite 100 prz.ti Boston, MA 02114-2017 ;,s www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): Address: ? ,e°' STD7-- 6 City/State/Zip: L 'J .'/Ui if ,67 (21a, Phone #: ,-56999., 776.- Are you an employer?Check the appropriate box: Type of project(required): I am a employer with employees(full and/or part-time).* 7. New construction 2. i am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8. ❑ Remodeling 3. I am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYProPriy e I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 5.❑ m I a a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp insurance.: 13. Roof repairs 6.❑We 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. 1.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 pai and penaltieyc of perjury that the information provided above is tru 'and correct. /A,jX� Signature: Z`'71.C-1(, 1i1 %11 Date: /Z /T 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration •.13 V 07/16/2023 RON BURLING. AWE RONALD R.BU Life ; :,xl 58 OAK ST f/4,4"m(411 . W BARNSTABLE MA t22660'7 Undersecretary Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Reggulations and Standards ConstructiQ upei449r Specialty CSSL-099695 spires: 12/03/2023 RONALD R B1R 58 OAK STREET j 115' -" WEST BARN 'A:' .• i kOt.Lt+aN33 Commissioner di0, i . FrndJ&, • • • 0.