HomeMy WebLinkAboutBLDX-24-150 - applicationOflicc Usc Only
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EXPRESS BUILDING PERMIT APPLICA
TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
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CEIVED
FEB 09 202"
AR I I",1E NTts
CONSTRUCTTON ADDRESS:
ASSESSOR'S INFORMATION:
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Map
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PRESENT ADDRESS TEL, I
coNrRACroR: ,4q/7/.Ei ) u{ncc /6 StJttr.t a re. tiMtEE /'lt o%(q {a 8 ' 367 ' r 69tt
NAME
E Residential
MAILINGADDRESS TEL. #
Est. Cost of Constsuction S-tsCommercial 9oo'ao
Home Improvement Contractor Lic. #/ z{18?-Construction Supervrsor Lic. # Obq qSZ
Workman's Compcnsation Insurance: (check one)
E I am the homeo' T", trtrI am rhe sole proprictor O t havc Worker's Compensalion InsuBnce
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?)Wood Stove
Insurance Company Name: _Worker's Comp. Policy#_
Siding: # ofsquares Replscement yitrdows: # /
Roofing: # of Squares- (!) Remove eristing* (mex. 2 lryers)
I I OtO Kings Highway/Historic Dbt m Rcplacing like for like
Replacement doors: #_
Insulation
Pool fencin
*The debris ivill bc disposcd of ar 4oQil 6 F qqaft0()41
I declare undcr p€nalties ofpedury that lhc stdamcnls hcrcin contsincd are Euc and conrcl to thc best ofmy knowledge rnd bclict I undcrstand that any falsc answc(s)willbej u51 cause for denial or licensc
Applicant's Signalurc
OtYDars Sig turc (or rttichmcnt)
Date:
Dale:
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Approved By
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EMAIL ADDR-ESS: yI TD N H L @ aoc , coa4
Zoning District
Ilistorical District: Ycs No Flood Plain Zone: Yes No
Watcr Resourcc Protection District:Yes No
Building Official (or dcsignec)
Parcel;
NAME
I
Lo.rtion of Frcility
for pro6ccution undcr M.G.L. Ch. 268, Scction l.
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Within 100 ft. of Wetlandsl
Yes No
A.The Corntaonwealth of Massach usetts
Departmenl of I ndustrial Accidents
1 Congress Sffeet, Suite 100
Boston, MA 02114-2017
www.mass,gov/d.ia
\Yorkers' Compensation Insurance Affidrvit: Builders,/Contrsctors/Electriclans/plumbers.
TO BE FILED WITH TUE PERMTTTING AI-MHORITY.
Name lBusincsyorganizrron/lodividual)i
Address: /b 5t^l4,rl
,n)enrud )lilhcc_
C, Ec(€
CitylStatelZip:lL4A /')4q Phone#: {vg _ 367 i (gE
. Any spplic{lt thar cb€cb bo( # I must 8lso fill out tic s.ctioo bclow shon ing thcir rDrtlfs' coEpclaatio. policy L&rtnrtioILr HomcowD.rs who subEit this Efrdavit indicating tEy arc doing !I t ork and thlrt hilg or-trsid. corfactors must subEit a !&1.l
tonEactors dlat chEck this box rnust &ch.d !n additionat strccistrowing th! osEs of tbr suEcorcr! tons.nd strtc whrt&r or
afr davit indicaing suctr"
Dot tlrosc cnthics harc
Arc yoll ttr cuployrr? Cl.rL ttr rpproprirt bor:
I.!l am a craploycr rxith cmployccs (full md./or pan-time)..
Zfil am a rctc proprlctfi or parEtlnhip and h8v. no rmplqycGs working for m. in? 8rry c!pr.fy. [No uro*crs' comp. insrmc. EquiEd.]
3.fll am r honro*,ncr doing rll uork nryscli [No,no*c{s' comp. hsuru,c! rcquird.] I
+.!l am a troncowrq ard will bc hiling contarloB to coDducl sll lryork on Ey Fopcrty. I will
crgurc thlt rll cpntradors cithcr hava u/ori(!rs' complosation itEuEnce or e! lolcproFictoE with no coployccs.
5. [-']l an a gcocnJ cont-rror and I hsvc hiEd tlc suEcontrcro6 list d on thc ritachcd stlcd.
-Thcar rub-ao[tlrroE hrvc amploy!6 and bvc wortas' coop. insurancat
6.!Wc uc a corpcaton .!td ia offc.rs havc crcrsiscd ttEir righ of rx.mpthD plr MGL c.
I 52, ! I (4), ad y,r tEvc no €$plqyr.r [No urukcrs' comp. ircrnoce rcquircd_]
Type of project (required):
7. I New consruction
8. ffRemodeling
9. E Demolition
l0 f] Building additioD
I l.EElectrica.l repairs or additions
12. EPlumbing repairs or additions
I 3 . fl Roof repain
r4.E]oth
c"mploy.cs. lfthg $lEconErdols hair oyccs, thsy musl proyid! thair wortlrs'comp. policy nuobcr.
I am an enEloyer thd is providing worken' conqansdion insurance lor nry enployees Betov is the poli.cy and job stu
irs
Sienature:
v Nrrtre'
Poliry # or Self-ins. Lic.Expiration Date:_
Job Site Addres City/Sute/Zip:_
Attach a copy oftle workers' compensation policy declaration page the policy number and erpiration date).
Failurc to secure covenge as rcquired under MGL c. 152, $25A is a criminal viol le by a fine up to $1,500.00
and/or one-year imprisonm cnq as wcll as civil penalties in the form of a STOP WORK ORD 6uc ofup to $250.00 a
day against thc violaor. A copy of this statement may be forwarded to the officc of Investigations of lDSurance
coverage verifcation.
I do hercby c*tify under the and penalties oJ perjury thd rte kfonwtion providcd abwe b bue and ancd.
Date: 2ls/zoz4
Phone #:{09- 761 _ fur(
Official use only. Do not t)fite in thb orea. to be complaed by city or town offrcial
Issuing Authority (circle one):
l. Board of Health 2. Building Deparment 3. City/TowD Clerk 4. Electrical Inspector 5. Plumbing tnspector
6. Other
PermiULicense #City or Towu: _
Aoolicant Information plesse prLtt Lesiblv
Pbone #:Contact Person:
U c{rrnonulalth o, IssacrtusalrsDivisin of Occupdknal LirrEUr!8o.rd o, AuiEing RqqgF ions and Stard.rdsc"n35$ff,S{ryvi'o'
C5-{,6/1982
MATI}IEW
CorEeudirr suFrviror
Unrt.trided - Bllildl]lgs o, ny usa gtouD uhici cod.in
bss liEn 36,000 c{tbk llet (S1 cuf*: n:fcr.) of eoclosed
spaca.
Falutt to poaaa$ 8 qtrlf cdilbn ot thc .ss.atuE!fis
Stlb Bundhg Co.l! it c.u!. lor rwocri(xl ol this sc.nsr,
For inffion about $ir iclns!cJFlnlngm q ttdt rulJt5foryrq
0710312021
,6 SWA[rl
MASHPEE oz
!o
IJV
Csnmirciorer daOA f,. V?-'tbL
THE COXIIIO'{WEALTH OF ITASSACHUSETTSOltlca ol Conluner Atllh & Buslnoss R.guhtlonHOE
MATTHEW M.
R.ga.mon vllld to, hdh,UrJ ur. oofy b.io!. th..plEdon d!ta. Itiatnd ltt ttto:Oltc. d Cootumt At rh rld Budnn RGguhdo,r
1000 W.tHng on $rEt . Slh.7t0Boion, l,A 02118
uo** u. ornr,a"i
16 SWAtt{ CTFCLE
MASHPEE, UA @849 [*.za /",,*
Und6rs€cEtary Nof vatld wtthout dgristure
*
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