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Home My WebLink AboutBLD-19-000759 °F•Y,yR Only dret - � 8 /9-on s y iAmmmt z 'Permit expires 180 days from = ::-- ' issue date EXPRESS BUILDING PERNIIT APPLICATION TOWN OF YARMOUTHRECEIVED Yarmouth Building Department _ 1146 Route 28 South Yarmouth,MA 02664 AUG 07 2018 (508) 398-2231 Ext. 1261 1 _ CONSTRUCTION ADDRESS: f / 7 (J /cf t/t k) S-1- H -r1 F -/ , ASSESSOR'S INFORMATION: • Map: / i Parcel: S OWNER: (half es Moms Qcge old it,con NAME PRESENT ADDRESS TEL # CONTRACTOR: d.ti a &w.0 2 :1 /44-(un4tc Alit Y .,,hn Sag WO 3d Y7 GADDRESS TEL# r94esidential 0 Commercial � Est.Cost of Construction$ /� ,��/d Home Improvement Contractor Lie.# 736 O O Construction Supervisor Lie.# CS- 07p ySr Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor /lave Worker's Compensation Insurance /� (� n Insurance Company Name: 60.M/Y10,4 MOMS TS. Worker's Comp.Policy# M N 03 o I 67 7 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares !"'l Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist ( )Replacing like for like Pool fencing *The debris will be disposed of at /&r -i Ut/ehn ArlfI Location of Facility I declare under penalties of.-'.. ed are true and correct to the best of my Imowledge and belief I understand that any false answer(s) will be just cause for. . / ... .E.. ., .•prosecution under M.G.L.Ch.268,Section L Applicant's Si. ....- ,e.� Date: / ?. iir- Owners Signature(or attachment) ¶>Jjjpjç7 Date: - i 4 7`�Q Approved BY - , Date: S^/ /�J 1-5—ptil ',Air r designee) EMAII,AD S: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: ' 0 Yes 0 No 0 Yes 0 No r.-4� The Commonwealth of Massachusetts r' gj _4'/ Department oflndustrialAccidents c vet 1 Congress Street,Suite 100 • =11Boston, MA 02114-2017 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organ irntion/Individual): 6 new �\\d,ti G ('A LC G Address: cra Attar k ;C A v-e-- i City/State/Zip: Ye,ifin . t-, MA- Oa6a/ Phone #: S6c( 3Rq 6.230 Are yon employer?Check the appropriate box: Type of project(required): I. I am a employer with 2.. employees(full and/or parttime).+ 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8, emodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'camp. insurance required]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on 10 ❑ Building addition ensure that all contactorsiso ' [w17J emploeither have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with nooemployees. 12.❑Plumbing repairs or additions 5.0 I am a general contactor and I have hired the sub-contractors listed on the attached sheet. These sub-contactors have employees and have workers'comp.insurance) 13. Roof repair 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,51(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that cheels box#1 must also 511 our the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contactors must submit a new affidavit indicating such tCoruractors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have employees. If the sub-contactors have employees,they must provide them workers'comp.policy number. I am an employer that is providne workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: et 1,77,11 nt-s if d4,-.1-3—7 �/l5 cirri,r.0 Policy#or Self-ins.gLic.#: �4 pia 16 77 Expiration Date: 3/c2d/ Job Site Addreess. G 1 � is � ,�jj/7 L '- A- City/State/Zip: Yarmu'v''l /y 10)66 Attach a copy of the workers' compensation policy declaration page(showing the policy n ber and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci • e •.• ties of perjury that the information provided above is-7ue and correct Signature: Date: 746F— Phone Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2. Building Department 3. City/I'own Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: