HomeMy WebLinkAboutBLD-23-000802 1
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RECEIVED
Office Use Only
YRR`irO R V D Permit#
N „,,.- .�/4 TAiug.5 ZO22 Amount,uu �� � p Y, Permit expires 180 days from
BUIL[71NG DEPARTMENT issue date
By.
EXPRESS BUILDING PERMIT APPLICATION U��3_ v2
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 384 Weir Rd Yarmouth port
ASSESSOR'S INFORMATION: _
Map: 126 Parcel: 9
OWNER: Karen Bruckhaus( 384 Weir Rd 508 258 0278
NAME PRESENT ADDRESS TEL.. #
CONTRACTOR: Troy Walls 87 Cranberry Ln South Yarr 508 394 1205
NAME MAILING ADDRESS TEL.#
0 Residential 0 Commercial Est.Cost of Construction$1 1 000
Home Improvement Contractor Lic.#105179 Construction Supervisor Lic.#044847
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: AIM Mutual Ins CO Worker's Comp.Policy#WCC 500 5009587-11/22
WORK TO BE PERFORMED
Tent E Duration (Fire Retardant Certificate attached?) Wood Stove 1-1
Siding: #of Squares 7 Replacement windows:# Replacement doors: #
Roofing: #of Squares (0)Remove existing* (max.2 layers) Insulation 1-1
rill Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing I I
411.4"
outh Disposal Area
The debris will be disposed of at: p
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 de ' io >f lic t and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signal e: Date: 8/12/22
ieF,06......_
Owners Signature attachment) v"\ Date:8/1 2/22
Approved By: Date:
_-/�-�
Building Official(or ee EMAIL ADDRES
Zoning District:
Historical District: ri Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes r' No Yes No
_ '� The Commonwealth of Massachusetts
11=l _ Department of Industrial Accidents
`�l= 1 Congress Street, Suite 100
=li_ �- Boston, MA 02114-2017
�;r• www.mass.gov/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): Walls Construction
Address: 87 CRanberry Ln
City/State/Zip:South Yarmouth,MA 02664 phone #: 508 394 1205
Are you an employer?Check the appropriate box:
Type of project(required):
1. ✓❑I am a employer with 1 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. 2 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.]
4.0I am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0I 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.t
6.1=1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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: Aim Mutual Ins CO
Policy#or Self ins.Lic.#: WCC-500-5009587-1122 Expiration Date: 11/22
Job Site Address:384 Weir Rd Y port MA 02675
City/State/Zip: P '
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: 8/12/22
Phone#: 508 394 1205
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#:
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Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construi lU .rvisor
CS-044847 gk pires:07/05/2023
TROY A WALLS
87 CRANBERRY LANE
SOUTH YARMOUTH MA 02664 ou
AO/S•S1:10N'
Commissioner (Lift Ai. &Cm -
t_F-Z Woin/no-rmoeedlo-/AaJc,iao.41(46/1(4
Office of Consumer Affairs and Business Regulation
1000 Washington Street a Suite 710
Boston, Massachusetts 02118
Home Improvemei:thContractor Registration
Type: Individual
j v/r1. Registration: 105179
TROY WALLS
, t
•87 CRANBERRY LANE ;S Expiration: 07/15/2022
SOUTH YARMOUTH MA 02664
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Update Address and Return Card.
A 1 0 20M•05/17
Ore Wa'n-rm6vruraaei ✓i6 2c tie/
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE Individual before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
i105179 _ i 07/15/2022 1000 Washin• _ =-t -Suite 710
TROY WALLS � ) 1 Boston 02118
t(` —f' '
TROY A.WALLS�N`
87 CRANBERRY LAN . .,.;:" / .I GL.� f li' •
SOUTH YARMOUTANA'02664 Undersecretary it 1'd WIthou si• '-ture
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