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Home My WebLink AboutBLD-23-002917 OF• .��R`Ir / j Office Use Only ' 9`-" :, � "1! 0 �� Permit# ��"�' o 1i' . y )7/l IZ�Z �i�-�— c� Amount dsa,ea (��]MATTA M f5� _J 'Permit expires 180 days from l issue date EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 NOV 2 8 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: "7 j_ c Je.SI- �c2/ryt pu-f Rd ( T( aim —I--_.___ ASSESSOR'S INFORMATION: Map: Parcel: OWNER:f4aj C4 a((kje 60 pit-/—f'f-6 b / NAME PRESENT ADDRESS TEL. # CONTRACTOR: E NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ I 00®,(D Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm s Compensation Insurance: (check one) lam the homeowner ❑ I 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: # 1 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing ______-, *The debris will be disposed of at: 0,0 1' [an S P(�,`. Locatidn 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• ., c.tian•' license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signae �' �� Asa, Date: "/ /'?� Owners Si_ ature(or a / hment) Date: l(/ Approved B Date: ///Jd/Z 2 Buildins.9fficial g e) 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 Department oflndustrialAccidents �� 1 1 Congress Street, Suite 100 a - Boston, MA 02114-2017 ,,,„ 4,- 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): Address: /;9 ( eS'l 1C.i.l rl 1 CtI \ • City/State/Zip: / ?21 L? Phone #: ,. C - ?4 ( cot L (: 67 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. _New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8. El 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 mY property. 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. 12.❑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.t 10•[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. r 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 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 certi under the pains and penalties of perjury that the information provided above is true and correct. Signature:.-' NO Date: Ve2g722 Phone#: -50 6 6 'y 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#: Clarke, Kristin From: Ricketts, Marcia J <rickettsm@vinfen.org> F ' E ' Sent: Wednesday, November 30, 2022 12:46 PM To: Clarke, Kristin NOV 3 Q 2022 BUILDING DEPARTMENT By' Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Hi Kristin My name is Marcia Ricketts my primary address is 442 west Yarmouth Road and change my address online with the assessor office The information in this e-mail is intended only for the person to whom it is addressed. If you are not the intended recipient of this e-mail,you are notified that any unauthorized disclosure, copying, distribution or use of the information is strictly prohibited. If you receive this e-mail in error and it contains health information please contact Vinfen's Compliance Officer at complianceofficer@vinfen.org. If you receive this e-mail in error and it does not contain health information, please return this e-mail to the sender at Vinfen and delete the email. For more information about Vinfen, please visit us at www.vinfen.org. 1