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Home My WebLink AboutB-14-13930� YAR i V - Permit � - 3 0� _y :VFee� ..0 emnt expires 6 months from MATTA n issue date. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: C� Map: Parcel: OWNER:, )aA,.4 tCcn-� -`ciftt ❑ Residential omm=ial ❑ Est. Cost of Construction $ ./ 1 i0,0 C®, 0y Home Improvement Contractor Lic. # iJ O i7 Construction Supervisor Lie. # Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ 1 am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: lt"il� Worker's Comp. Policy# h J) 13 - tt LlY L 4vV C `4Y WORK TO BE PERFORMED ❑ Tent (Fire Retardant Certificate attached) ❑ Wood Stove Shed ❑ Siding: # of Square ❑ Replacement windows: # ❑ Replacement doors: # 21Re-mof: # of Squares Stripping old shingles* *The debris will be disposed of at. ❑ Insulation () going over layers of existing roof ❑ Old Kings HighwayMstoric District RoofinglSiding (lake for Like) Location I declare under penalties of perjury 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 revocation of my license and forprosecution under M.G.L Ch. 268, Section 1. Applicant's Signatm: _ (A-) ! �_ _ yGLI�.�% Date: !L� / 7 / /y Owners Signature (or attachment) " K p ,� S Date: `ry y' Z % y Approved By: Data: Building Official (or designee) Zoning District: a.s ^ Historical District: ❑ Yes )k No Flood Plain Zone: JNYes ❑ N Water Resource Protection District Within 100 it of Wetlands: ❑ Yes )(7 No Yes ❑ - No L t n� APR 17 3/01 The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le¢ibIv Name (i3usiness/Orl;anization/Individual): ( A) .t .t..R- Address: City/State/Zip: v Phone #: Ci- of ) i 6 u— a0 q/ Are you an employerYCheck the appropriate boa: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I empl ees (frill and/or part-time).* have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' corric. insurance required.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 LF] Plumbing repairs or additions 12. oof repairs 13.❑ Other_ *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infommtion. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees, they must ptovide 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. #: 6 td o f 3 6� q i//. 4.6 "�' / j Expiration Date:D Job Site Address:C7 Vw_- tt 4&jln IS)_ 13OA2% /0-� t1'�City/State/Zip: ►n Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. r96 ..- use City or Town: area, to or town official Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our inured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (CHUB-5B44640-7-13) 06-13-13 TO 06-13-14 POLICY NUMBER EFFECTIVE DATES EDWARD J MCGRATH INS AGC PO BOX 1003 DENNIS MA 02638 NAME OF INSURANCE AGENT ADDRESS PHONE # DOWNEY, WAYNE B DBA HOME 9 WHITE LANE EXTERIOR SPECIALISTS SOUTH DENNIS MA 02660 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) MEDICAL TREATMENT �� The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the #" NAK413`G "OSPITAL {' ADDRESS .064748 W20PIG02 . ; . TO BE POSTED BY EMPLOYER Office of Consumer Affairs & Business Regulation - Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR) Consumer Affairs and Business Regulation .3 Home Consumer Rights and Resources Home Improvement Contracting Home Improvement Contractor Registration Lookup You can search/filter the registration list by any of the criteria below. Search by Registration Number 1150108 Search Search by Registrant Name Search by City Zip Code Search Registrants Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund history. The list is current as of Wednesday, April 16, 2014. Search Results REGISTRANT RESPONSIBLE REGISTRATION NAME INDIVIDUAL NUMBER WAYNE B DOWNEY DOWNEY, WAYNE 150108 SIDING SPECIALIST ADDRESS P.O. BOX 23 SO YARMOUTH, MA 02664 EXPIRATION STATUS DATE 03/07/2016 Current http://services.oca.state.ma.us/hic/licenseelist.aspx 4/17/2014 t Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supenitor Specialh License: CSSL-098855 1 WAYNE B DOWNJEY '_ PO BOX 23 S.YARMOUTH MA 0 ` J.4- Expiration Commissioner 06/02/2015