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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664 OCT 03 2018
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: r2 L/ /Oe,,' dai B❑iL T
_
ASSESSOR'S INFORMATION:
'',,(( Map: Parcel:
OWNER: Melt] 7c,/(o (QL/ rotes /0l/
NAME PRESENT ADDRESS TEL #
CONTRACTOR:
NAME MAILING ADDRESS TEL.II
Afesidential 0 Commercial Est.Cost of Construction S 2/ SOO
Home Improvement Contractor Lie.# Construction Supervisor Lie.N
Workman's Compensation Insurance: (check one)
41 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
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares 17 (///Remove existing*(max.2 layers) Insulation_
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at:
Location of swill y
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 aruwer(s)
will be Just cause for denial or revocation of my license and for prosecution under M,O.L Ch.268,Section I.
Applicant's Signature: Date:
Owners Signature(or attachment t'27e_e_ ____... Date: /(1)a-6
Approved By: 6Date:
ding (or esignee) EMAIL ADDRE
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 11 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes [1 No 0 Yes 0 No
__� The Commonwealth of Massachusetts
t
"--re t Department of Industrial Accidents
PIIf==I I Congress Street,Suite 100
51 rc Boston,MA 02114-2017
4r www.mass.gov/dia
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\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING ALITHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): nnet Pcjrfo
Address: 2't 14t,,r //e/ 4,
City/State/Zip: lith-4. c?,,,04,hz( 44 Phone#:
Are you au employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or pan-time).' 7. 0 New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3tlRam a homeowner doing all work myself[No workers'camp.insurance required.]t 9. ❑Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 0 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 t have hired the sub-contractors listed on the attached sheet 13.0 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 MOL c. 14.0 Other
152,11(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that rhert-t 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.
:Contractors that check this box must attached art 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: 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 above is true and correct
Signature: W.s /tele Date: /0:--,--e)
Phone#: .4 64'6 ,-)q6-q -
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 S.Plumbing Inspector
6.Other
Contact Person: Phone#: