HomeMy WebLinkAboutBLDX-26-16 RECEIVED '
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EXPRESS BUILDING PERMIT APPLICATION
TOWN Y M0U11-1
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02,664
(508)398-2231 Ext. 1261
CONSTRUCT/ON, 135_South Shore Dr_unit 2a
OWNER: Charles Little 35 Soundview Cir. White Plains N.Y. 914-224-6121
N,N,Mt r„SLN1 J DITR sS A it
CONTRACTOR: Jon D Colman 9 Cherry Ln. W. Yarmouth MA 508776-6851
NAME - MAILING ADf ItLSS In.4
EMAIL: rabunker@comcast.net
)CIResidential (]Commercial _Est.Cost of Construction$ 2000.00
Hormer:rower ls' r .*. '. N*V.
Home� t c c,. hr. � , #144538 4- Lk,#CS-088700
WORK TO BE PERFORMED
Teat fir:at'hMS y Mitt at Certificate respired) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #€€Squares Insolation Temporary Mobile Mime
Solar System IESS System Clfimaey Peace
*Please submit utility disconnect letters for electric&gas—structures over 7.5 years old require historical review
*The debris wiu be disposed of at: yarmouth land fill
1 declare under penalties of that the statements stein containat arc tine and correct to the best Katy knowledge and belief. !understand diet any false answcr(s)
will be just cause for d revocation of my and for prosecution under M.G.L.Ch.268,Section 1. 7
Amtlir rt's Signature: /—' !)r-te 12_- 2 9- ` �\`+�_
Owners Signature( attachment) Date:
Approved By: Date:
Building Ofrinialtne fix?
The Consmonwarafth of Massachusetts
Deportmeatt ordtdnstrial_accidents
9 _ , ce of In vrat g ns
Lafayette Clio Center
%'� 2.4nenare de Boston.L l 02111-1750
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print I,et!ihly
Name(Business/Organization/individual):Jon Comas
Addre<&c:9 Gh Y 1-n-
City/state/2ip4:W_Y arrraaulk lib 02573 Phone5 8 5t
Are you an[enph r?d."fra&Or appe rirle beta '�. �am�i general-�i7i3't"rF'k4iE�f Type*Of
� ,-
I. F ate a employer with h_ Q New cramtriiti
employees(full�cor� tt»t- eep_* have the
2. I mat a �r the, sheet. 7_ U Remodel
ship and have tier employees Thnt'rt3uu c hale . El Demolition
working for mein any - employees and have r 9addition
�aoalc s'cop.: �ccrn i t+i e::
5- 0 we we a cerreg mei.its .'I ortrira3 emirs Or additions
'e their I I sing or additions
3.El I am a homeowner doing all work h -�
tt sV camp right riferemption per MGL 12 Roof repairs
rc_ 152,§1(4)-and ne haw nu
workers'
1_.nE t t't fllac fTt
employers_[No corms.insurance retired.]
*Any applic-.mt that clretl s bat#l mast also tiff uut the section heir:showing their nesters'compertsitiort policy rntcrrnl aiiem.
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
mtkryloppc WON. pa3mer..waa+kx+ ar ahoy ssaard-raaava.t ,atka�i maserinarse.._ •s
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
iptfm-swntiius.
Insurance Company Name:
pot ik o Self-if. t u: it' F v,--.,3 w,e< oe-
Job Site All/dress: CityiStatelZip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure dss*Lorterp orini,f?^»rsr vkk r fv4 mind". sss 3i,A.4-M(I r >c? .4 g.41n the.irasseuaifinn ofvrisnir alit romaltitec of a
fine up to$I,5 0.00 and/or one.-year imprisonment as welt as civil penalties in the firm of a STOP WORK.ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insure nee.coverageverification...
I do hereby c fy under the pains an penalties of perjury that the information provided above is true and correct.
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,' Offficlisi use as*. liks ton*lit this osto4,lilt be eomple by-eik yortuenvefrwill
. City or'Rrail. reVIllattielMISe#
Issuing Authority(cheek me):
IDBoard of Health 20 ilitednig Department 30Cityirtniat Clerk t ilectrical Inspector SEfriumbing
Inspector 1 . !`. _ — -
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Aff*S::.& Business Regulation
HOME IMPROVEikENT-CONTRACTOR
TYPE Individual
Registration tIP
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RICHARD BUNKER . ...
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RICHARD A. BUNKER :;...:::. ......
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18 ESSEX WAY
64/
BREWSTER, MA 02631 4
Undersecretary
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