HomeMy WebLinkAboutBLDX-24-134 - ApplicationEXPRESS BUILDING PERMIT APPLICATIO
TOWN OF YARMOUTH
Yarmouth Building Department
1 146 Route 28
South Yarmouth , MA 02664
(508) 398-2231 Ext. 1261
Office Use Only
Permit exptes 180 days ftom
issue date
$Lox-&r.,t-ttq ,I RECEIVED
FEB o52o2tr
Perm
1\U
CONSTRUCTION ADDRXSS
ASSESSOR'S bIIORN{ATION
/ru uu
Mup Parcel
lrlc IJ LLL
NANTE PRESENT ADDRESS
CONTRACTOR:
NA\,IE
,[Residenrial
Home Improvament Contractor Lic. #
h htr /"(,77 /NG AD TEL #
DCommercial tt5G10 Est. Cost ofConstmctioo $effi6G7 Construction Sup€rvisor Lic. #L iL&
\\.ORK TO BE PERFOR]\IED
(Fit-e Retardant Certificate atllrchcd?)
Workman's Compensation Insurance: Jcheck one)i I am the homeowner y'l am the sole proprietor a I have Worker,s Compeffation [nsurance
InsurcDce Company Name: _Worker's Comp. policy#_
,rdfr q
Wood Stove_
ReplaceBent doors: #_
Itrsulation
Siding; # ofSqua Replacement witrdows: #_
Roofing: # of Squares_ ( ) Remore eristing* (max. 2 layers)
_ Old Kings Highway/Historic Dist. ( ) Replacing like for like
'The debris will be disposed ofat:(.11
Location ofFacilit"v
I dcclare under penaltics ofpedur! thal the stat€ments herein contahed arc tlue and conect to the best ofmy knowledgc and belief I undersrand that any false answer(s)
h
will bcjust cause for d
Applicant's Signaturc:
enial or revocation of my_lEEt9{ld for prosecution under IU.C L Ch 268, S€dion Iz#--
Owoers Signature (or eftachmeot)
Date
Drte:
DateApproved By
CTr, p p 86 6 c c rftc\ s t, net
/*"
Building Official (or designe€)EIVL\IL ,ADDRESS
Zoning Djstrict
Historical Disrricr: a Yes Y No
Water Resource Protection District
; Yes {No
/--l \
-Amount L, (./
a\
OWN*ER:
Tent _ Duration_
Pool fencing_
Flood Plain Zone: i Yes
Within 100 ft of Walands:
i Ycs 1No
s-\The Commonwealth of Massachusetts
D ep artmenl of I ndustr ial A ccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\\:orliers' Compensation InsqraDce Affidavit: Builders/Contractors/Electricians/plumbers.
TO BE FILED WITH THE PERIVIITTING .A.IITHOzuTY.
nt Info ation Please P t e
CName @usiresyorganizationlndividu al: C h r i 5 lOA/.t f '1,;/a h
Address: / 1--e"rnl.Lin<R"/,.
CitylStatelZip:Col";'t-r4</ c26,1 Phone#: ?7-^3t^t o
Arc you a0 €mployer? Chcck the appropriatc bor:
I I am a .mployer with _.mployees (full and_/or part-time).r
I arn a solc proprietoror parhership and have no cmployees working formc in
any capacity. [No wortien' comp. insuranrc rqquircd.]
3.! I am a homcowncr doing all work myself. [No workeG, comp. insurance .tquircd.] r
4. ! I am a homcowncr and will bc hiling contracto.s to conduct all work on my propc.ty. I will. cnsurc that all conFactors aithd havs workcrs' compcusation insurancc or a:c solcwith no cmployces.
5 I am a gencral contictor and I havc hired the sub-confactors listcd on thc attachcd shect.
Thcsa sub-contactgN havc cmployecs and have workers'comp. insurancc.t
Wc arc a corpomrion and i!5 officcrs have cxercised $cir right ofexcmptjon pcr MGL c.li2, i l(4), and lrE halc no employecs. [No workcrs, comp. insurancc rcquired.]
6
'Any applicant that cbeck box #l must also fill out the section bclow showing their workErs' cornpersation poliry inforaration-T Hooeo*ncrs who submit dis affidavit indicating thry arc doing all work and thcn hire ousidc conE-actors hust submit a newlcontraclors that chcck this box must auachcd an additional sheci showing thc namc of the sub-conEactors and state whcther or
affi davir indicating such"
mt thosc cntiti.s have
employaes. lf thc sub-confactors have employecs, thcy must prcvidc their workcrs'comp. policy number
7.
8.
Type of project (required)
New construction
Remodeling
9. I Demolition
Building addition
Electrical repairs or additions
Plumbing repairs or additions
Roof repairs
14. Mloth ,irle,
10
ll
12
13
I am an emploler thal is providing worken' compensdtion insurancefor my employees, Betow is thepoliq, and job siteinlornntion-
Insuraace Company Name:
Policy # or Self-ins.Uic.*: Ch<,bb# I Oe 51 Expiration Date lo //tq
Job Site Address 3 Lr;l/- u""l +1.,Ciry/State/Zip:ceoz
Attach a copy ofthe workers' compensatiotr policy declaration page (showing the poticy number and expiration date).
Failure to secure covemge as required under MGL c. i52, $25A is a criminal violation punishable by a fine up to $ I,500.00
and./or one-year imprisonment, as well as civil penaliies in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1l l/y'()
I do hereby
S isnatrre:
catily under the pains and penalties of perjury that the information
D
provid.ed abov,e is trui and correcL
^r", ?15/2 3
Phon e#'77q-97f - /o/c
OfJicial use onQ. Do not rrrite in this area, to be completed by city or town olJicial
Issuing Authority (circle one):
I. BoardofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing lnspector
6. Other
Permit/License #
Phone #:Contact Person:
Citv or Town:
a
(,
cs-.t 12862
COrulrMA
cofl: missionc, d* 1.d6..,rt.-
12122t2024
-o
12
fo
THE COMMONWEAL OF MASSACHUSETTS
Office of Consumer Business Regulation
1000 - Surle 710
118
Home on
185690
01i31t2026CHRISTOPHER TRIPP
12 GERALOINE RD
COTUIT, MA 02635
IriE COMI\IONWEALTH OF ,tIASSAC HUSETTS
HOE
a:Ha{ts I0PHER
CI]RiSTOPHER C
Updat Addr6s and Rerurn c,rd
Roglrlralion valid for indlvld(rluse orly bolore theErpihriond.re lflound ftllm ro:
Oftie ot aon3uns At'fairs ahd Blsln6ss Regulatlon
10{X}Wa3hington Slr.et . Suil€ 71!
12 GERALOINE RD
Not valid wiihout signature