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Home My WebLink AboutBLD-19-001559 og•Yi„• RECEIVED 1 e Use PD--Only� /Ssy SQ C O - kiSEP 14 2018 +Amount wV taC5:4'•+•�•• c.aB --- Permit expires 180 days from t R {{ TME5i issue date err EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231� - Ext. 1261 CONSTRUCTION ADDRESS: 3g flit(-e_�fi W a / ASSESSOR'S INFORMATION: Map: Parcel: `"^ OWNER: Tali� S V•eV-0 in pont/set Ntt- 14. MA cot-sow-63 6o NAME PRESENT ADDRESS • 0.2115:, TEL N CONTRACTOR: NAME MAILING ADDRESS TEL# N4esidential ❑Commercial Est.Cost of Construction s 7000 00 Home Improvement Contractor Lie.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ❑ 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 ea Siding: #of Squares Replacement windows:# / fid Replacement doors: # p I91 Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation &J 1%Id Kings Highway/Historic Dist. (Replacing like for like Pool fencing 9e Vs. ioe /%a qc . •The debris will be disposed of at: / NsfC72—. Location of Facility I declare under penalties of perjury that the statements herein contained are true and coma 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 I. Applicant's Signature: Pleb Q ® Date: Owners Signature(or attachment) „�// e. Date: Approved By: G Date: 7 • Building•• cial . design ) EMAI`r•DRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No rifle" The Commonwealth of Massachusetts • ` ` to `�—t'i Department oflndustrialAccidents 7_--ilotg Congres Street,Suite t.• _" �_'� 1 BostonSMA 02114-2017 100 www.mass.gov/dia *v `� Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. /Applicant Information Please Print Leeibiv Name(Business/Organization/Individual): Ta U ' TV o Address: 5$ tic t e wfi (.)c H City/State/Zip: Jar-tri oll po r Phone#: 5-0 $- Q z2- a y y 9 • Are you as employer?Cheek the appropriate box: Type of project(required): 1.01 am a employer with employees(fill and/or part-time).* 7. 0 New construction 2.01 am a sole propriety or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.) 9. ❑Demolition 3.21I am a homeowner doing all work myself[No workers'comp.insurance required.]t • 4.0 lam a homeowner and will be hiring contractors to conduct all work on my property. l 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.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.? 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,41(4),and we have no employees.[No workers'comp.insurance required.] *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 end then hire outside contractors must submit a new affidavit indicating such. IConersctors 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 subcontractors 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 andJob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 and penalties of perjury that the information provided aboveabis true and correct PiaeSignature: ,X f! (/ �(.a Date: //i Phone#: SDrR' — `l402- a veil Official use only. Do not write In this area,to be completed by eh,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#: virod 'ibJoel,,,LQ/ Am ( g °� 4:2"ap, sa� 17 nL b Sb A41/44 / 0LIi -D91) ; C" CLAM S ) 0