HomeMy WebLinkAboutBLDX-23-15644 - application'Jo
RECTIVSD
Nov 15 2023
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth , MA 02664
(508) 398-2231 Ext. 1261
L €o,tht-,1 qr. S ',lh%oon/l/4CONSTRUCTION ADDRESS
ASSESSOR'S INFORMATION
Map:Parcel
OWNER fiAild @tLeY 3t /'4!p/1d tlosuaoPo.tcil nA 0632 (s'ar)'bq-$3?
NAME PRESENT ADDRESS TEL. #
coNrRAcroR: fllfir$al Dol H, u-4
MAILING ADDRESS
o'z/;3a-7 16
NAME TEL #
Home Improvement Contractor Lic. #/z5g7L Construction Su
Workmaa's Compensation lnsurance: (chcck onc)- [ am the homeowner ( I am the sole proprietor , t have Worker's Comp€nsation lnsurEnce
WORK TO BE PERFORMED
Tent Duration
fResidcntial
Siding: # of Squares
o Commercial
Insurancc Company Name: _Worker's Comp. Policy#_
Roofing: # of Squares_ (
_ Old Kings Highway/Historic Dist
(Fire Retardant Certificate atteched?)
Replacement windows: #_
) Remov€ eiisting* (max. 2 layers)
( ) Replacing like for like
Est. cost ofconstruction $ S@ 'OO
pervisor Lic. #cs- ob498L
Wood Stove_
Replacement doors: #_
Insulation
Pool fencing
4
+Thc dcbris will bc disro6cd of st 'rou)i o( ,/*ouoa+4
I declare under pen lties of
will b€jusl csusc for denisl
Applicant's Signature:
OrN nerc Sign.tura (or sttrchman
Approvcd By:
Locrtior of Frcility
perjury that thc sldamcnts hcrcin containcd ore true and conact
Building Official (or dcsi$cc)
ofmy md for prosccution undcr M.G.L. Ch. 268, Scction I
to &c bcst ofmy knowlcdge and belicf. I undcrstand that any false answc(s)
Datc:ttlt5l'*,
tt lts I4nt2Dete:
Date:
Zooing District
Historical District: . Yes No Flood Plain Zone: Yes No
Watsr Resource Protection DistrictYcs No
Within 100 ft. of WetlandsYes No
llTD^/i4L@ AoL , cot4
EMAI RESS
a,The Commonwedlth of Mdssachusefrs
D ep artment of Industrio! Accidents
1 Congress Street, Suite 100
Boston, MA02114-2017
www.mass,gou/dia
\Yorkers' compensation Insurance Affidevit: Builders/contrectors/Electriciens/plumbers,
TO BE FILED WITH TEE PERMITTING .{UTHORITY.
t
Name (Busitresyorganizatior/lndividual):/Y)n'rrrcu Du!*vL
Address:
City/State/Zip ,r,lA. O'%t/4 phone#:C;o g) zat - b<4
Ar! you rr eeploy.r? Ctrcck th. .pprcprLt bor:
t.! I am a employcr wift cmployels (fuu and./or palt-time).r
zSI rm a sotc nronrictor or parbcrship and havc no cmplcry..s working for EE in
alry clpacty. [No wolt rs' comp. insurancc rcquirEd.]
:.! t am a horrowncr doing dl \iork ruysell [No ulorkas' comF in$ra rcc Equhld.j t
I !trl 8 horEvenr( atd w b. hiring oonbartoE to condlE all u,ort on Itry Fop€{ty. I will
cnsurc thlt all contsaarors cithcr havc norklts' compcosStion ir|suIltlc! or alc solcproFricbs with no copllyras.
5.[ I ao a gcocral courrcor and I have hircd thc suEcontrcbre listrd or thc alrchcd shcct
Thcsc sub.coltrlcbls hrvc tmployccs aod havc wolkrls' coop. iruurmcat
O.I Wc an a corporxlon and its oficccs havc cxacisrd thei! right of acm!,tjon p.r MGL c.
I52, gl(4), ad v,r h!r,c no coployccs. [No wortcrs' comp. iamrcc nquf*-1
hsurancc Company
Poliry # or Self-ins.
Job Site Ad&css:
Attrch a copy ofthe worken, compensrtion policy declaration page (sho
Type of project (required):
7. ! New constuction
8. I Remodeling
9. fl Demolition
l0 E Building addition
I I . E Electical repairs or additions
12. I Plumbing repairs or additions
13. ! Roof repairs
14.8 Other
Expiration Datc:---
City/State/Zip:_
norktrr' caopcnsaion policy i!trormltioD-
hil! or.Gidc coiElcsls tnust submit s ncw afrdrvit indicting suctL
oflh! suEcontsicto6 ud sr! whcthlr qr Dot thosc 4titic! bavccmploycrs lfth. $EconEactors have cmploye€s, they must proyidc thcir wortrrs'comp. policy Dur,bcr.
I an an enptoyer thal b providing worken' conEansdion insurance lor ny enployees. Betol, is the pohcy mtd job site
.Arry sppliclrt that checks box # I mlIst aiso fill out th! scction bclow sllowiry thcirI Homco,lrcrs who subEit his Efrdavit indicdiog 6e-y ur doing !.U wo* ar; OsrtContraotors trat chcck this box must &chrd an rdditiona shishowlng thc naoc
wln number and expiredon date).
fine upto$1,500.00
$250.00 a
Failure to secure coverage as requircd under MGL c. 152, $25A is a criminal violation pun
and/or one-year imprisonmeng as well as civil penalties in the form of a STOp WORK ORDER and a
day against tirc violafo
covcrage verification.
r. A copy ofthis statcment may be fonrarded to thc Officc oflnvestigations ofthc DIA for
I do hereby and peaalties oJ perjury thd lhe information provided above is bue and cofted
')
#30?' 16
al use only. Do not write in this arca, to be coDq)lded b! city ot tot n offrcial
Phone #:
OfJici
Contact Person:
City or Town:
Issuing Authority (circle one):
lA ,Ue,^t oil2dz
the
I' Bosrd of Health 2' Building Deparment 3. city/Town clerk 4. Electricel tnspector 5. plumbing tnspector6. Other _
THE COTIO'{WEALTH OF
Oltloa ol Cootlmat}FT
MATTHEW M.
MATTIIEW M,
16 SWAIi{ clRcLE
MASHPEE, MA OAO49
IAS3ACHU3ETT3Bu-i-t tuauLdoo
[*-.(A /-r*.
Undcts€crotary
0 Commonwtllth ol mas3achu3ltt3
Bo.rd ol Building
Davition o, OccuPltional Lictnaura
.nd St ndards
rct'. O7 lO3l2O21
16 SWAIN
MASHPEE
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