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Home My WebLink AboutBLD-19-001153 ",OP'• 4(44. 1 Office Use Only ). �.• !Permit# G�^� O .: 'IX. C .Amount 5 v 1/4\"`^:te" crd 'Permit expires 180 days from ` • '� , t, .fq ` IS-- issue date - EXPRESS BUILDING PERMITAPPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 2 7 2018 South Yarmouth, MA 02664 AUG (508) 398-2231 Ext. 1261 }�7�� BUIL r ,RTMEN CONSTRUCTION ADDRESS: V '7 t czJIJy, uY ASSESSOR'S INFORMATION: p•� Map:r Parcel: .q ( 0 r//ryq a /OWNER: �CJh& ` - /Mirk v,o ocl'-e ?7 SqeN/ ic('e ed iI o18" s NA'IME' SENT ADDRESS . TEL. # CONTRACTOR: /J A y'µ-)..e. -DDow JU .c NAME �y.,ING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ 9 o t a, B a Home Impprovement Contractor Lie.# Construction Supervisor Lie.# Workma¢'s Compensation Insurance: (check one) t7 Q'I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# • WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares J.2._ Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation I�ld Kings Highway/Historic Dist. ( l�j Replacing like for like Pool fencing *The debris will be disposed of at 9j/)1)11,Q�t di /_ Location of Facility 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 for prosecution under M.G.L.Ch.268,Section 1. It 6/> 3> �, Applicant's Signature: w(tr •.i � Date: a � p /li Owners Signature(or attachment) ? Date: Sr ,Z,��! 1/ Approved By: ✓ ,-w Date: c+ -k.1C -/F Building Official(or designee) EMAIL ADDRESS: 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 • _ . The Commonwealth of Massachusetts + I _ Department of In dustrial Accidents ,I I Congress Street, Suite 100 • „ Boston, 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/Organization/Individual): . )h1) el- 6-1A21(1/4,4 a oocl Address: 7 -R& 2N ptcc,Q KC City/State/Zip: "jatN O AF° ,2-{' Phone #: /8 ( i q a 8 0 Are you an employer?Check t e appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑Demolition ❑� y [No workers'comp.insurance required.] 4.L?J`am a homeowner and will be hiring contractors to conduct all work onroe I will 10 ❑ Building addition my property.rtl ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp. insurance.: 13.❑Roof repairs,,•n/ 1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other �(d ,/," 152,§1(4),and we have no employees. [No workers'comp.insurance required.] in/," *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide 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.#: - Expiration Date: Job Site Address: 0 11 /3 cutivi-or% viZ� City/State/Zip: e rpt, Attach a copy of the workers' compensation policy declaration page(showing the policy 4t 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 certi, ' • the pain nd penalties of perjury that the information provided above is true and correct Signature: r Pi/2�/fV Date: Phone#: "142/ — tilj 2. g‘t 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/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: