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Home My WebLink AboutBLD-23-003553 •YgR- C ,� (� f��'G�. Office Use Only ..Og . /) ,�w �r� . Permit# 414 C. O - „� • H Amount I , $.urr n <,�...• rear, Permit expires 180 days from issue date 0--3 --0(535 5'3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department -- - -- 1146 Route 28 DEC 2022 South Yarmouth, MA 02664 508 398-2231 Ext. 1261 BUILDING DLPARTfvI[fvy CONSTRUCTION ADDRESS: 503 Rt 28 #21 West Yarmouth ASSESSOR'S INFORMATION: Map: Parcel: GayWells 503 RT 28#21 West Yarmouth 617 584 8096 OWNER: NAME PRESENT ADDRESS TEL. # Richard F 11 Pinehurst Drive Wareham MA 02571 508 789 0684 CONTRACTOR: NAME MAILING ADDRESS TEL.# 0 Residential 0 Commercial Est.Cost of Construction$ 0Oh.oh 166941 CS-104977 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner El I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 8 Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation I I I I Old Kings Highway/Historic Dist. i Replacing like for like Pool fencing I i Yarmouth *The debris will be disposed of at: 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 bejust cause for denial or re ation of lice e or pro cution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: /2/4 Owners Signature(or attachment) /�'� Date: ✓��tt��- Approved By: Date: /2'o27 2 2- Building 0 (or "gnee) EMAIL A SS: Zoning District: Historical 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 Department of Industrial Accidents �sfUlr= 1 Congress Street, Suite 100 -1=f= Boston, NIA 02114-2017 www.mass crov/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): Richard F Prouty/RP Construction Address: 11 Pinehurst Drive City/State/Zip: Wareham MA 02571 Phone #: 508 789 0684 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with 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.] 9. ❑Demolition 3.01 am a homeowner doing all work myself. [No workers'comp_insurance required.]t 10 ❑Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp.insurance.t replace sidewall shingles 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. 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: _ 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify nder theepp 'ns p ties o perjury that the information provided above is true and correct. Signature: ,� Date: // Phone#: 5-0 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts tel Division of Occupational Licensure Board of Building Re ulations and Standards K µ.,oast(` l��isor v CS-104977 "* Eeic4pires:07/06/2024 RICHARD F 0101 5 11 PINEHUR`�, 1'va O WAREHAM ryp3 1 . 1/4) Corr—ssioner ;; `'�r:rt;..�, From: HICRegistration(SCA) hicregistration@state.ma.us c Subject: HIC Registration Card Date: June 2,2022 at 8:00 PM To: b.brokenshelll @verizon.net Dear Registrant, Attached please find your new HIC registration card,you must sign the card using ink. Sincerely, Home Improvement Contractor Registration Program THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Maus and Business Regulation 1000 Washington Street-Same 710 Boston,Massa•_+sisetts 02118 • Home Improvement Corrtractor Registration type: Pd4da I CHARD PROUTY H�*75Yawm: 15179t1 5.Q'A PPC STFgJC 11ON8 BULS)rJG SERVICE i _ =:4v�,Yxr1 T719�2R2d 11 P 1Erk1HST DRIVE eYAREHAM MA 02 71 u►dale A00,00a and I1t*rn Cad THE COMMONWEALTH OF MASS ACHUBETT9 taco d Cenareer ANNAN b ethane RapArtion Rgarien valid der i.+6vidui ear tray Ge1cv.e+. HOME MPRO mien-CONTRACTOR tmoraINA dale.N 4a..,d.6toa M: TYPE.olio WW Me*of Corm Altars and Srrwas t�aiason ReTesYdfort elli11101C91 1000 Wrhneaan 9raer -S*M TM 4244' W191102J Readan.MA 0210 �:•.VMA6F PPc:.ti.-Y :1,8'A RP CCRSTR,.,C7 ON b B'JLDNG A�'.•]'_ "411 4t;".MRQF Ptir, :" V 3 NAri$fAM MA 0t: Jndmsocrebar. N01 valid without signature • a7/Mb