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HomeMy WebLinkAboutBLD-23-005989 J fl z K )L 3J )23 ..oi':'�44 RECEIVED Office Use Only k.: O. Permit# C �V LPV,, y APR 2 8 2023 Amount 5-0 .CAD at w-: ..e . .,_.:,.. �__._ . _- Permit expires 180 days from BUILDING DEPARTMENT issue date BY - - S L1n— 3 -6O511g1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 61 Captain Wright Road ASSESSOR'S INFORMATION: Map:77 Parcel: 15 OWNER: Rhonda Falcone 226 Bankside Hollow Acton MA 978-394-7884 NAME PRESENT ADDRESS TEL. # t° :CONTRACTOR: Cedarworks, Inc. 32 Beechtree NAME MAILING ADDRESS AA.-alDr. Q, SS�t,,( 508-648-6117 „� I TEL.# 0 Residential ❑Commercial Est.Cost Vof Construction$7000 Home Improvement Contractor Lic.#176751 Construction Supervisor Lic.#104167 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance insurance Company Name: Kerry Insurance Worker's Comp.Policy#400-401-7463 WORK TO BE PERFORMED Tent L Duration (Fire Retardant Certificate attached?) Wood Stove I I Siding: #of Squares 4 Replacement windows:# Replacement doors: # Roofing: #of Squares ([1=1)Remove existing*(max.2 layers) Insulation I 1 I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing F *The debris will be disposed afar M.A. Frazier 10 Kear Cr. Wellfleet MA Location of Facility I declare under penalties of perjury that ie states nts 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 rev. .tir 9f my cen and for prosec fre+a er M.G.L.Ch.268,Section I. Applicant's Signature: Date: kli 'i23 r' Owners Signature(or attachment) Date: 1(z I2-3 I Approved By: e/ Date: i /-2 Building Official(or d n EMAIL AD SS: kathleenyerkes@gmail.com 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 I r. Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 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): CedarWorks, Inc. Address:32 Beechtree Drive City/State/Zip:Brewster MA 02631 phone #: 508-648-6117 Are you an employer?Check the appropriate box: Type of project(required): 1.0✓ I am a employer with 3 employees(full and/or part-time).* 7. ❑New construction 2.01 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. t 9. ❑Demolition ❑ y [No workers'comp.insurance required.] 4.01 am a homeowner and will be hiring contractors to conduct all work on m YP property.e I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.I We are a corporation and its officers have exercised their right of exemption per MGL c. I4.0Other siding 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. 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: Kerry Insurance Policy#or Self-ins.Lic.#: WCC 4004017432 Expiration Date: 6/2023 Job Site Address:61 Captain Wright 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 cer under the p ns and penalties of perjury that the information provided above is true and correct. Signature: Date: ?,3 Phone#: 9 3R o 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#: k 0 c cc § \ 2 c Cu_ q � 2 c o tO N g 3 / 2k F- ~ -43. ƒ� ■ © �� ■ . c k\•2 k � � � ° C CC o • ® 22 k2ra/ ( (0 q � = �w k-k� e R _ _ & _ ; 2 c -- � » ist� .. Ai = - g § � . • 2 •! $ 0§w - 1 — _� u) u- > a/ �0 / cts -CR / CDJ.< z I- c % U &2 � C e • E 2 k$$§ 2 Q 22 E cr2§02 a) > E \ _ 7 o_ kooE oo k» U ' E ƒ o e o ) _� ° Iv CM 2 \ 2 2k a \ Q= m czcae ZO =—wo � to 0 bk -z \ E cC RA `m0a �3 � >�3G uc \\/ (E�� / / mk\ OcQ Oj Ix f k/7 2■ cc w cc Z0\k� \ ae io < § 0 CC i ƒ®ƒ 0 021 • Division Budding of of Massachusetts Bard of wilding Prof CiceusUre Cons lah°ns and CS-1 � i609rvisors�n�r`� (24167 CHR1S7 BREWSTR DRNE ES Ptres:0770 23 FR NIA 02631 • r)fsl=h1U_� e commissioner 'A tJCrncu,t V