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HomeMy WebLinkAboutBLD-23-003609 Ciatid Y Office Use Only `1R /7 Pemut# L 72/ © Amount 3-e. do nAri- n ttt, *wno Permit expires 180 days from issue date �t D--:23 -0036 0 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 JANr ...032023 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT 7 Sparrow WaySouth Yarmouth By — CONSTRUCTION ADDRESS: h ASSESSOR'S INFORMATION: Map:88 ParceI:34 OWNER: James Mullane 7 Sparrow Way S Yarmouth 508-398-8989 NAME PRESENT ADDRESS TEL. # CONTRACTOR: John LeBoeuf PO Box 21 Centerville,MA 02632 508-280-4156 NAME MAILING ADDRESS TEL.# 0 Residential ❑Commercial Est.Cost of Construction$16,400.00 Home Improvement Contractor Lie.#1 17872 Construction Supervisor Lic.#0 1 0 1 6 1 Workman's Compensation Insurance: (check one) 0 I am the homeowner p I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Atlantic Charter Ins. Co Worker's Comp.Policy#WCVO1275553055 WORK TO BE PERFORMED Tent LI Duration (Fire Retardant Certificate attached?) Wood Stove Li Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 7 ED Remove existing*(max.2 layers) Insulation I I Old Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing *The debris will be disposed of at: Town of Yarmouth Disposal Location of Facility 1 declare under penalties of perjury that the statements herein contained are rue 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 licen d or p recut under M.G.L h.268,Section 1.Applicant's Signature: John A Leboeuf µ' [ l// Date: 0.I 1/03/2023 Owners Signature(or attachment) s attached authorization Date: Approved By: Date: /—3 -2 3 Building Official(or designe E AIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No { STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION FOR A BUILDING PERMIT Date: December 30,2022 I, James Mullane_own the property at 7 SPARROW WAY in SOUTH YARMOUTH , MASSACHUSETTS I have authorized JOHN LEBOEUF to act as my agent to apply and obtain a building permit in accordance with 780 CMR the Massachusetts State Building Code. SIGNATURE O N _ DATE 4- `3e) 2sL OWNER'S ADDRESS 7 SPARROW WAY SOUTH YARMOUTH MA OWNER'S TELEPHONE 508-398-8989 Jack LeBoeuf Building& Remodeling P.O. Box 21 Centerville, MA o2632 cell: (508) 280-4156 7 5f A rrc .x �" '4,4 to Address and Rot..Cud. 5 7 4/(P9'K.x;e/ 41, Azi,,,,,,,,,, --,---A THE COMMONWEALTH Or MASSACHUSETTS Office of Consumer AftBYs 8 Business Regulation Registration valid for individual,,IxR only batons the HOME IMPROVEMENT CONTRACTOR expiration date.Hlodsd relur.+ru tYPE.IruKv.rir at Office of Consumer Affairs and Business R0q1.14000 RR$=ittatiou E.Offfetign 1000 Washington Street-Sr de 710 11.7872 1175/20.4 Boston,MA 02118 ,}OHN A LEBOEUF 1`, A JOHNA LEBOE OF l ' 438 CRAIGSILLS BEACH RO -x�-ll,- : apv,.n . F HYANNIS,MA 02801 Undernene18!3 Not valid without sl re Commonwealth of Massachusetts ' i% „t Division of Occupational Licensure Board of Building Regu rations and Standards µ CS-010161 4,• b s ;,;I t`tpires.09/3012024 JOHN A LEBBEUF.'4 �, PO BOX 21 ' ' CENTERYiLLit MA r '`or.tNh'.1.1 Commissioner .:y „ rf v" rr-1�.4:02- r U The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 •�•''V Workers' www mass.gov/dia W Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): John A LeBoeuf Address: P.O BOX 21 City/State/Zip:Centerville, MA Phone#: 508-280-4156 Are you an employer?Check the appropriate box: Type of project(required): am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0l am a sole proprietor or partnership and have no employees working for me in 8. ®Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. 9. ❑Demolition ❑ y [No workers'comp.insurance required.] 4.01 am a homeowner and will be hiring contractors to conduct all work on mYP property.e 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. 12.['Plumbing repairs or additions 5.ElI 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.: 13. ✓❑Roof repairs 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. f 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: ATLANTIC CHARTER IN COMPANY Policy#or Self-ins.Lie. : WCV01275305 Expiration Date: 03/08/2023 Job Site Address:7 SPARROW WAY S YARMOUTH,MA 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 pains and penalties of perjury that the information provided above is true and correct. Signature: . �� Date: 01/03/2023 Phone#: 5 8-280-4156 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#: