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HomeMy WebLinkAboutBLD-23-003543 41, C-W- t )Csl 36 ( Office Use Only ��~ COrmit# : /�'� REC ' 1VE o y T__ . __ __�. Amount 60`CC) rW7'T- 1+ s 4 "' w d,. FM 1 l', Permit expires 180 days from �;.t /i issue date BIJI . NGa DEPARTM+NT i 6Lr1)"c2-3 -ed35t3 EXPRESS BUILD ' `-'' :41 Y---- ' M 'LICATION TOWN OF YARMOUTH ' RECEIVED Yarmouth Building Department 1146 Route 28 � South Yarmouth, MA 02664 DEC 2 8 2022 (508) 398-2231 Ext. 1261 __, BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 48 Deb's Hill rd. Yarmouthport J to) ;f a p By ______ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Michelle Ryan 48 Deb's Hill .Yarmouthport 774-487-5407 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Ken Couture 8 Great Western , S.Yarm 77-810=0257 7 7(1— /O— D.27 NAME MAILING ADDRESS TEL. ©Residential ❑Commercial Est.Cost of Construction$2000.00 Home Improvement Contractor Lic.#206 436 Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) XI am the homeowner AI am the sole proprietor El I have Worker's Compensation Insurance Insurance Company Name: Commerce Worker's Comp.Policy# WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:#3 Replacement doors: # Roofin •r.... .. #of Squares (a)Remove existing*(max.2 layers) InsulationI I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing 1 OIL '` ^^^ �h 7� *The debris will be disposed of at: Yarmouth transfer station Old Townhouse S. Yarmouth 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 for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: �y,/ Date: 7(//C/d;,_________ Owners Signature(or attachments f/!/=pi _ - —'--"-" Date: �j r� Approved By: Date: /2- — '2 2 Building Offici or g ) E ADDRESS: Zoning District: Historical District: L' Yes `:_? No Flood Plain Zone: Yes - No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes 7 No • The Commonwealth of Massachusetts Department of Industrial Accidents + 1 Congress Street, Suite 100 Boston, MA 02114-2017 IMP=�•`'y 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): Mi.l' ,ie/ ;,� Address: 48 ,E /14I/ Rd �' City/State/Zip: ' ✓,,i„a f th %-1 // j' L-)/V Phone #: 7 `f ` �` l_ 3 4L5 Are you an employer. Check the appropriate box: Type of project(required): l. 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. [No workers'comp. insurance required.] 9 Li] Demolition- 4.[l am a homeowner aridProPe will be hiring contractors to conduct all work on myI will 10 ❑ Building addition �' ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.ElElectrical repairs or additions 12.E Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.x 1 •❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other .r�jr ] 152,§1(4),and we have no employees. [No workers'comp. insurance required.] /ppfr(,Ptr(I)T *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. $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: 42 City/State/Zip: ,17,r r,e, ifr, T 104 1 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: r =/ _ - Date: " Phone#: 7 7,4 4 f'w07 / �io� - �,a 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#: