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Home My WebLink AboutBLD-23-000429 L" " I' )Z2 Office Use Only ��' V*YRR Permit# C.,K*3 7 7 1 '` H Amount l ��`00 O - -rrwl *" ,.-' Permit expires 180 days from issue date &&D -23 -6DZ) W-9 EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH RECEIVED Yarmouth Building Department __-.-....--_P....._.---_ 1146 Route 28 JUL 2 6 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 LUS , l3 �r CONSTRUCTION ADDRESS: Y3 Oa - / Ue ASSESSOR'S INFORMATION: Map: Parcel:OWNER: IpaiiV,P_(Mc (fir r tpis -t3 OCeg" NAME( PRESENT ADDRESS TEL. # CONTRACTOR: VOC(-07_,t__ S cobs K n Q. (3Q X 3"/lI c( y_rn o ` 77 q-35 3 67 SS NAME MAILING ADDRESS TEL.#/It p Resi ,..7 /dential 0Commercial Est.Cost of Construction$ , ° Home Improvement Contractor Lic.# ((95- p f3 8 Construction Supervisor Lic.# O 8 k OLV3 Workman's Compensation Insuranc : f check one) 0 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 .1 Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares 1 9 Replacement windows:# /O Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation n E101d Kings Highway/Historic Dist. . l,Pal Replacing like for like Pool fencing n *The debris will be disposed of at: , r Location of Facility I declare under penalties of perju , 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/ca'on of),,,license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: i/�L'�� i---- Date: 7/16 aoa'..- \c„) Owners Signature(or attachm; t 7 ' 1 Date: f"( ' C. 2"+ Z. - Approved By: __ 722..._ 7-2 ?' < Date: Building Official(or des' EMAIL ADDRE Zoning District: Historical District: Yes -; No Flood Plain Zone: I Yes - No Water Resource Protection District: Within 100 ft.of Wetlands: .- Yes No .. Yes 7 No • The Commonwealth of Massachusetts ne 1 =* _ L Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 =s ~ sq•s. www.mass aov/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): PA`k t�� C6D5' Address: P. Q. 6 0> 3c r City/State/Zip:y-Poct M 64- Oa-{o 7 s Phone#: 74'- 3S3 —6 Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with employees(full and/or part-time).* 7. ❑New construction 2g1am a sole proprietor or partnership and have no employees working for me in 8. remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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.❑we 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 er rep ' s and penalties of perjury that the information provided above is true and correct. Signature: Date: 7Ai& ra-OD-0.- Phone#: 771(— ? 6 Q 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): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Division of Occupational Licensure • Board of Building Regulations and Standards Const ion SUPPgvisor •P CS-081040 $ I5jcpires:04/04/2024 PATRICK H*COBS 28 WHITTIERiDRIVE DENNIS MA 638 ,'0 / tl.ixt1.3)` Commissioner doe. f VZvnjia_, THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 165888 05/14/2024 PATRICK JACOBS D/B/A P.JACOBS CUSTOM CARPENTRY AND REMODELING PATRICK JACOBS 28 WHITTER DR. DENNIS,MA 02638 Undersecretary