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HomeMy WebLinkAboutBLD-23-000624 IT" O R urnS Office Use Only $ i Permit# MATTACM F. — ��--•--R�^^ -7 AmomnL V r d `krnrarrtoaQ A UG 0 4 2022 Permit expires 180 days from A l7 qq>'issue date BUILDING DEPARTME NT 5L'b—Z 3 bOO(2- EXPRESS BUILDING PE 64 1.1 __.__ -_ ON TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /itd 1,1,47git)57 ),,v/2/-.2©U7 w7i2e ASSESSOR'S INFORMATION: I Map: Parcel: OWNER: Cr, G £ '/3/57z /(o& Yi® ,5 - yo2 v� //i j• AME PRESENT ADDRESS TEL. # CONTRACTOR:,25.i7f//Q COX 4A}0 i g tave /� w- ,io & "4i L —c5al NAME MAILING ADDRESS TEL.# PResidential 0 Commercial Est.Cost of Construction$ !a a'42° Home Improvement Contractor Lie.# /004,59 Construction Supervisor Lic.# 0635- ' Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor i4 have Worker's Compensation Insurance Insurance Company Name: / Z / '�'-ccWorker's Comp.Policy#H WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares /5Z ( /Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic/Historic Dist. ( Aeplacing like for like Vei a 4��,, i G Pool fencing ►'^a'N1 �i lCe�jr l f Ke 87 y1,v *The debris will be disposed of at: )//pirra� / 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 be just cause for denial or revo tion of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: � � Date: 7/2 9/Z-� Owners Signature(or attachment) / Date: Approved By: g _�_, Building Official(or de. -e Date: EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes U No J=---- The Commonwealth of Massachusetts 11. —lei— Department of Industrial Accidents '�el= 1 Con cress Street, Suite 100 4 moms mawr= Boston, MA 02114-2017 ttar :.5''y` _ www.mass.;ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual). .0) Address: / 1 1isfiez)27 q/,iv City/State/Zip:1�y�j, - -, Phone #: Are you an employer?Check the appropriate box: 1.[ I am a employer with ? Type of project (required): employees(full and/or part-time).* — 2.E I am a sole proprietor or partnership and have no employees working for me in . Rem delinruction 8 any capacity. [No workers'comp. insurance required.] 8• _ Remodeling 3. m— I a a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my roe I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance. 1 Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]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: WAP2} jam`, Policy#or Self-ins. Lic. #: �J p./0 , y7..7. Expiration Date: 7 f j/�Z 3 Job Site Address: �) z•IJ,(' ��7. City/State/Zip: y'/pp, ‘2,t, ,/�. 'j. 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: 7 Phone#: T 2 _ 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#: Office cif CI;o01010euWieeeshrtriAgfitre'efid "Iti Win, `suite 10 v� i �,v+�mem Contractor attlitts Registration' y CO)(CO . mion YARktanh,MA 5s LAVENbegt r e Expiratian: 0 Oft*otterosamer MAW* SOUP NPROVOUvirS rah "PtC V'ib COX,MVC� 00104 I DA inD N.COX IV LAVENDER Ls YANMOOK 144 Ce673 '1;4**A' *****641/;;O:Vithli-*MOW Stall tind!"4"40tt ary Commonwealth of Massachusetts ItDivision of Professional Licensure Board of Building Regulations and Standards Cons W t I rti visor CS-063537 y�' * I pires: 10/15/2023 DAVID R PO BOX 401 SOUTH YARMSIU•ff S'S1i Commissioner c s401. 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