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Home My WebLink AboutBLD-23-000744 O1•YRR` j Office Use Only 0 Permit#V , . ATTA M [SE4. lAmount 5n.i5 Permit expires 180 days from {issue date EXPRESS BUILDING PERMIT APPLICATIONP- -23 ,OM eig TOWN OF YARMOUTH Yarmouth Building Department [RECEIVED 1146 Route 28 South Yarmouth, MA 02664 LAN 1 2 2022 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /D �( 37l eo ' ! bl( u -tom BUILDING DEPARTMENT ASSESSOR'S INFORMATION: Map: Parcel: \ I r OWNER: )( roL Vie-LEVoki `6 A,1"157 1.• On /-9i3-8a19--S336-- NAME Npb,-r-,3--d ,5'/94--,A(/ai0.PRESENT ADDRESS TEL. # CONTRACTOR:j9earfWDab W, /^ g5 Q--95-0.NAME MAILING ADDSjTEL.# Residential 0 Commercial Est. Cost of Const ction$ tJ� Home Improvement Contractor Lic.# /3 8934 Construction Supervisor Lic.# GS- of pryp� Workman's Compensation Insurance(check one) 0 I am the homeowner I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: /.��l16 Worker's Comp..Policy# -70g-- VISp17 p a2 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # g Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation..*4.y1 4,{aiv7j( Old Kings Highway/Historic Dist. "�� ( ) e lacing like for like Pool fencing i t im Serw-3 *The debris will be disposed of at: ge -044'c ') Location of Facility AO- 6 ‘(61/ 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 evo i of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ''/ Date: ' eAV0201— �/ Owners Signature(or attachment) /1 ii Date: 8. l2/Z Z Approved By: ti.►t Date: "I). Lk Building Official or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 0 No • / ' tl.' '\ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,54..5�•y< _ www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Pleas Print Leaib[y Name (Business/Organization/Individual): / ,,,r3 p `�� J 1 L O. Address: 765 ,/ y , City/State/Zip: er-i c.4041—eq_Q(),5ay Phone #: ss � 9,32'-d-- Are you an employer?Check the appropriate box: Type of project(required): 1.L1 I am a employer with employees(full and/or part-time).* — 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8• Q lZemodeling ` 3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑ Demolition 4.0i am a homeowner and will be hiring contractors to conduct all work on mYProPam' e I will 10 ] Building addition ensure that all contractors either have workers'cd*ipensation insurance or are sole 11.Ell 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.: i •[1]Roof repair�sl 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.D Other A-)T/" �� 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. y� Insurance Company Name: /*9 U16.1d,7s Policy#or Self-ins. Lic. #: 7PJ-V.y— /A-7.? /7/_01. Expiration Date: 571/2� Job Site Address: 70 t L4; T� ine£ , /f City/State/Zip: Z �L_ -,/./ MC edgy Attach a copy of the workers' compensation policy declaration page(showing the policy rrSimber and expirationdate).b� p 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 certi der the pains and penalties of perjury that the information provided above is true and correct. Signature: ? tiai / �( �Q f Date: // /?� Phone#: ,�oU'_ ,�v/ `9j�(/ /// 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#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual $egistratlon Expiration 138936 01/21/2024 DBERT J.MORRIS JBERT J.MORRIS 45 JENNIFER CIRLCLE .. st.a IDGEWATER,MA 02324 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Re ulations and Standards Cons lljbt isor CS-058542 y�' '* I Aires:08/09/2023 ROBERT J M;OR' to 145 JENNIFER CIR p q. BRIDGEWATER MA ' < -IVOi alb Commissioner dat