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Home My WebLink AboutBLD-23-000799 O :• - i . y {{Permit# f L ESE i Amount NATTACM S° 1Permit expires 180 days from l issue date Li)--z3—b799 EXPRESS BUILDING PERMIT APPLICAT TOWN OF YARMOUTH .� D E I V E D Yarmouth Building Department AUG 15 2022 1146 Route 28 South Yarmouth, MA 02664 B (508) 398-2231 Ext. 1261 sY CONSTRUCTION ADDRESS: L-2— i l� 3•\-, /\ \JJ , - (''' 4 r stv d--1- L. . ASSESSOR'S INFORMATION: ,/� Map: Parcel: •._-- OWNER I 75 C 0' 0,1` 1 l IL ,-^ s C 1)e vt . -�^CR-'_ NAME PRESENT ADDRESS TEL. ~�� TEL. # CONTRACTOR:CV/' glr)Y►‘G,.‘ , T.d alel Pk i Q7S Li- , Ecpe —Sgki � O MAILING NAME RESS TEL.# Ce sidential ❑Commercial Est.Cost of Construction$ LI LI CO . 0 0 Home Improvement Contractor Lic.# \ 9 I 'i1 Construction Supervisor Lic.# KS-S-G ' C Workman's Compensation Insurance.: SAheck one) ❑ I am 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: # Roofing: #of Squares \ ) ( 1,/Kemove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 1 S ° t I 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 revoc ion of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /1 ` 2--�-2_2._N.. Date: // Owners Signature(or attachment) r Date: /S f l kl/ 2B Z L- Approved By: ' Building Official(or d gnee) EMAIL ADDRESS: ate: "� Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes ❑ No ►\ The Commonwealth of Massachusetts r _g�_ Department of Industrial Accidents ;,.. 4=. r;' 1 Congress Street, Suite 100 Boston, MA 02114-2017 0, = M.._•`" www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): "Q V l k in '—'t'I 7 .ipP y` Address: cl I CA P g ,- r .e �..- i-. �. a� rT el_s 1-41;0--c. City/State/Zip: M ci,L.. Gs cPhone #: , C' Co — T h — 6 Are you an employer?Check the appropriate box: Type of project(required): I. a employer with employees(full and/or part-time).* — 2. 7. _ New construction I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8• Remodeling[ 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.] 9 Demolition 4.[I am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.[ Electrical repairs or additions 5.[I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12._ Plu n.ing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 1 •is 'oof repairs 6.[We are a 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 41 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: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing he 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 S 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: —)a — r) 6'`1 Date: `'l d L1-- Phone#: S—C G \ 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Consltr itt tlil Upervisor CS-105918 Eic,ppires 09/15/2022 MOHHMED S RAHMAN r 70 OLD PHINNEYS LN BARNSTABLE MA 026 1(0r `1 tip ' Commissioner dtA f YF4m • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual fle_gjArvism Exui i 173492 10/08/2022 MOHHMED RAHMAN D/B/A ALL CAPE BUILDERS MOHHMED RAHMAN 70 OLD PHINNEYS LN BARNSTABLE,MA 02630 ` Undersecretary