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Home My WebLink AboutBLD-19-1154 O• i 41 s Amount c& 1 Permit expires 180,days from (issue date . EXPRESS BUILDING PERMIT APPLICATI Jet E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department pus 27 2018 1146 Route 28 South Yarmouth, MA 02664 : i!-.I ^it-MUM:'/ (508) ry Q 398-2231 Ext. 1261 By — CONSTRUCTION ADDRESS: a b0 U.\ c9,-.e -- C-7,-C-7,- e.`\e__ - ASSESSOR'S INFORMATION: ,/ Map: (� Parcel: OWNER: Y�.1L.s�Nh. Cat) a o.r.`c�a,.I- Cw -c\Q-- '- A- GO-1- (occ"! NAME PRESENT ADDRESS - TEL. # CONTRACTOR: Se ...a_ as 0+bO1l °-- //�' NAME MAILING ADDRESS TEL# R'Residential ❑Commercial Est.Cost of Construction S RI Sao Home Improvement Contractor Lic.# 1%\t a.S Construction Supervisor Lie.* 1#)CQrcalfrrnaik Workmat)e Compensation Insurance: (check one) RR''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 .4\e.4 ` Siding: #of Squares a Replacement windows:# t[ (o.ns\l�rc\tCMReplacement doors: # Roofng:��#of Squares ( )Remove existing* (max.2 layers) (0/, Insulation 6kiVdld�{� Kings Highway/Historic Dist ( )Replacing like for like Pool fencing ao6 "The debris will be disposed of at 'S ci )(CO Nr – &r# \\ \A tXNN 9\017-gl - c e.A.A� . Location of Facility I declare under penalties of perjury that the stieuwents 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 •cation of my license an rosecution/• M.G.L.Ch.268,Section I. // / 4,Applicant's Signature: . . — \ _ — a_,4 Date: g'/ar el t )(Owners Signature(or a -chment) - ,�,.� dye Date: grk 7 / tis �` 8— 19 - , Approved By: ..� _ / Date: Building Official(or designee) EMAIL ADDRESS: Zoning District Historical District 9 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 R of Wetlands: ' 0 Yes 0 No 0 Yes 0 No • `""� • ^ The Commonwealth of Massachusetts �/ e _ti Department oflndustrialAccidents =-77iI Congress Street, Suite 100 ='a�= � Boston, MA 02114-2017 -Zs`40 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leaiblt Name (Business/Organization/individual): Address: Z & ciulz..z." ! -.c4c2& yP City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/orpart-time).• 7. 01�]aw construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. rE'Remodeling • any capacity.(No workers'comp.insurance required.] 3.1011 am a homeowner doing all work myself[No workers'comp insurance required.]: 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 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.El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.❑Other in§l(4),and we have no employees. [No workers'camp.insurance required.] *Any applicant that checla 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 :Corm-actors 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-contactors 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.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number 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 certify under the pains an nalties of erjury that the information provided above is true and correct Sivlature: */..P1-(-14 6. /lam Date: Phone#: '7 S\ - GO '' _ G �7 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#: