HomeMy WebLinkAboutApplicationc
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RECEIVED
t)EC 21 2023
BUILDING DEPARTMENT
EXPRESS BUILD
Officc Use Only
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Permit expires lEo day5 froln
issue dale
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LICATION
TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth, MA 0166+
(508)398-2231 Ext. l26l 1152 {e'r}) fi ore 0a --,€
[!!"n Parcel
CONSTRUCTION ADDRESS:
ASSESSOR'S TNFORMATION:
N,A.r\lE ^/c L So,t
mercial
PRESE}.]T .{DDRESS
G ADDRESS
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CONTRACTOR] UT il..atn .9.o t*4
TEL. #t7
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NA.!tE
! Residential
IiIome Improvement Contractor Lic. #
Workman's Compensation Insurance: (
/
Est. Cost ofConsuuction S
5 Construction Supe rYisor Lic. #
am the sole propri etor - I have Worker's Compensation InsuEnce
A.-1 4'A,t {-*r,r-)7 gs76
ok?Lo b
Wood Stoye_
Replacement doors: #
Iusulation
lq
i I am the homeowner
losulancc Company Name:
Tent
Worker's Comp. Policl#
\\.ORK TO BE PERFO R\IED
Duration (Fire Retardant Certificate attached?)
Siding: # of Squares
-
Replacemert wind on* l-!2
Roofing: # ofSquares_ ( ) Remove existing* (max.2 layers)
_ Old Kings Highway/Historic Dist. ( ) Replacing like for like Pool fencins
rThe debris will be disposed ofar
I declare under pena.hies ofpequr] that the statements herein conrained
wrllbe just cause for denial or revocation of
of Frrili n
coftect to the best ofmy knowledgc and
.G.L. Ch. 268, Section l.
Dale
lief. Ibe
I
that any false answer(s)
/,.*
hners Sigln ttfie lor ettachment)
licant's Signature
2-Date
Date:
Buildiry Official (or designee)E]VL,\IL ADDRESS
Zoring District
Historical District: a Yes I No Flood Plain Zone: , Yes lNo
Warer Resource ProtectioD District:i Yes aNo
Within 100 ff. of Wedands
! Yes I No
Approved By
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I
TEL. #
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4
Name@usinesyOrgadzarionnnd.ividuat): (wAA.X
Address:
CitylStatelZip:
apPIicant tha! check! box I t must also fill out thc section bclow iiowin
The Commonwealth of Massachuse s
D ep artme nl of I n d ustrial A c c ide nts
1 Congress Street, Suite 100
Boston, MA 02114-2017
\\iorkers, compensatior ,",,.".""'#I;friiii?rY!Jr7""^r,^,r,,,/Erectricians/prumbers.
TO BE FILED WITH THE PER]VIITTINC .ATITHOzuTY.
cant rmati PIease t bl
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otroN'41!#0,b// ?t 7 f7r
Type of project (required)
7.
8.
9.
10
L__.t 1\nstructon
odeling
Demolition
Building addition
I I.E Electical repairs or additioos
12. I Plumbing repairs or additions
13.
'I4.
Roof repairs
Other
Homeowners who subrrut thls affidavlt irdicating thry are doilg all work andlcodfactors that chack this box must anached an additional shee! showing the
eoployees. lf the suLconE_actors have employccs, d1ry must providc thcir wo
thcirworkcrs' coopcnsation policy informatio[
Arcn hirc ouEidc contractoE aoust submit a new afidavit indicating such
nalne oftha sub-cootractors and state whethea or not thosc cntities have
rkcrs' coftp. policy ouElber.
a employer with employees (full and./or pan-time).*
am a sole proprietor or parorership and have no employees
any capacity. [No workers' comp. insurance required.]
! I am a homeowner doing all work myself [No workers, comp. insurance required.] i
I am a hor.eowner and will be hiring contracrors to conduct all work on my propcny. I will
ensrre thai all conEactors either havc worl(ers' coopensation irsu-ance or arc soleproprictoG with no .rtrployees.
5.! I am a geueral cont-actor and I have hircd the sub-cont-actors listEd on the attachcd shecr
These sub-contEctgas have employecs and have workers' comp_ insuraacc.i
6.! We arc a corporatioD and its officers have exercised their right ofexemption pra MOL c.
152, $1(4), and we hav. no employees. [No workers' cornp. ilEurdnce rEquiEd.]
wo.king for me in
Are you an employer? Ch.ck the appropriate boll
I
I dm an emploler that is pro
informotiott-
Insuraace Company Name:
Policy # or Seif-ins. Lic. #
Job Site Ad&ess
Attach a copy o
Failure to secure coverage as
and./or one-year imprisounen
day against the violator. A co
coverage verification.
viding workers' compensation insurancefor nE enptoyees. Beloll, is the polic!
kfl'tR"s-t- fl:Nf- ( a
NC-t375 Expiration Date
and.job stte
/+\,/
9rA tJ <_City/State/Zi 02ee
fthe workers' compensation policy declaration page (showing the policy number and expiratio n date).
required under MGL c. 152, g25A is a criminal violation punishable by a fine up to $1,500.00
t, as well as cMl penalties in the form of a STOP WORK ORDER and a fine of up to $250,00 a
py ofthis statement may be forwarded to the office of Investigations ofthe DIA for insurance
o.€
I do hereby certify under the p the information provided above b trud an
ate l2 /,,T;
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rrecl.
e
P
alties of per
Official use only. Do not wfite in this drea, to be completed by city or town ofJicial.
City or Town: .- permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
4. Electrical lnspector 5. Plumbing Inspector
Phone #:Contact Person:
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Licensee Details
flemographic Informetion
ull Name
Name
License Address Information
MA
02114
United States,Pcde
License Information
Licenses
Lice SEn Type
usln6ss As:s
se struction Supervisor
ton
ssue Oate:
Status:
Curragh Dobbin lnc
Renewal
Building
115t2011
Active
Dale of Last Renewal
Expiration Date:
Today's Date;
'1ot20t2022
10110t2024
12j212023
uisite lBformation
lnlormationNo
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