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EXPRESS BUILDING PERMIT APPLICATION r o�
TOWN OF YARMOUTH OCT 18 2018
Yarmouth Building Department L
1146 Route 28 81,11 °A 53
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 11n M1�t
✓CONSTRUCTION ADDRESS: 1 CLA2A S4- y,.
Sott*tt Yar .oc2?' A Oz-roc,ci
ASSESSOR'S INFORMATION: •
Map: Parcel:
i/
WNER MA1T EMC(CI . IMS
V NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL#
Residential 0 Commercial Est Cost of Construction$ I CCC •OD
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Wor 's Compensation Insurance: (check one)
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 Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing la
'The debris will be disposed of at DeV4O tS{ "I GarCtQ_
Location of Facility �J �`"
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 MG.L Ch.268,Section 1.
Applicant's Signature: Date:
/Owners Signature(or attachment) Cbku• Date:
'
i •',
/
Approved By: ‘,27-217 v - Date: 10-19—,
Building Official(or.estgnee) MAIL 'DRESS:
Zoning District:
Historical District: 0 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
a
.� ., `'" . The Commonwealth of Massachusetts
t�-1 = L Department of Industrial Accidents
• =^el= 1 Congress Street, Suite 100
_4f1_ Boston, MA 02114-2017
" ,=„4 www mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information c Please Print Legibly
Name (Business/Organization/Individual): M{r-ineve y,AARI
Address: 1 C LP1 QA 5+ So 4h '(e.rvtAeL.114 (AA_ 0244.4.1
MA
City/State/Zip: Sou1n "far w10 njn
Phone #: 5-DA- ZZ 1- 738$
Are you an employer?Check the appropriate box: 0214./ Type of project(required):
1.0 lam a employer with employees(full and/or part-time).* 7. 9 New construction
2.9 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 workmyself t 9. ❑ Demolition
���❑...___///... [No workers'comp.insurance required.]
4. I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 ❑ Building addition
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-contactors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13. Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.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 contactors 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: 1 C L-AR A S+ So tntin %Ietr vvotA414City/State/Zip: 024,C q
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 u I.er the pa',s and'enaltie e perj'ry that the information provided above is true and correct
Signature: /r � , , . - Date: I i t,
Phone#: 67)6-Z2I- 7 3 es
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#:
' • Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as "an individual,partnership, association,corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial •
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
r ' Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
•
•
x.01.-y4 TOWN OF YARMOUTH
BUILDING DEPARTMENT
`�\",^ ra 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 261
°��"'" BUILDING DEPARTMENT
TOTAL DEMOLITION SIGN-OFF FORM
State Building Code (780 CMR) Chapter 33, Section 3303.6-Service Connections
"Before a building or structure is demolished or removed, the owner or agent shall notify all
utilities having service connections within the structure, such as water, electric, gas sewer and
other connections. A permit to demolish or remove a building or structure shall not be issued
until a release is obtained from the utilities, stating that their respective service connections and
appurtenant equipment, such as meter and regulators, have been removed or sealed and plugged
in a safe manner."
"All debris shall be disposed of in accordance with 780CMR 111.5."
Building or Structur oca on: Map: Lot:
Owner's Name: M AE I Address: I CLA' A Phone:
Contractor's Name: Address: Phone:
Eversource: Date:
By:
Title:
National Grid: Date:
By:
Title:
OP Water Dept.: Date:
By: -
Title:
o Board of Health: Date: 10— t s —I`'
By: j�G.c0.t✓wit.Hac.11.
Title: 7 0 '
Condition:—
o Fire Dept.: Date: 1 Z:• 1 S "I i
By: /, A p 7 . GNU C k
Title: /L I-C--
11
Historic Commission: Date:
By:
Title:
Conservation: Date:
By:
Comcast: Date:
•
3/15
SERVICE NO. -1-30G5
NAME /
STREET I CL- 1p
RR 672F eV
VILLAGE Muni y RR MDf��,-1
METER NO.
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37 •-III FL .
201- 2Slave . • 5TDP orr 1-Pr vi
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.p4•y TOWN OF YARMOUTH 410)6 5
; WATER DEPARTMENT •
p be Z. 99 Buck Island Road
VC:7g West Yarmouth, MA 02673
Telephone: (508) 771-7921 • Fax: (508) 771-7998
•
BUILDING PERMIT APPLICATION
DEPARTMENTAL
pSIGN OFF TRANSMITTAL SHEET
Bldg. Site Location /C'7g# a Sf J ;
Proposed Improvement: AA d if 0o
Applicant _—MAS °`!/ — -- -- — —
Address 1 _C LAZA St..... ._ Tel #: S472Z1-138 _ Date Filed: IC, t7l2C1.$
RESIDENTIAL AND / OR COMMERCIAL BUILDING !!!
Water Department: Determines Compliance of Water Availability and or Existing Location
Engineering Department: Determines Compliance for Parking and Drainage
Conservation Commission: Determines Compliance to Wetlands Acts; i.e. If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Ocean, Bogs, Bays, Marshland, Etc...
Health Department: Determines Compliance to State and Town Regulations, i.e.,Requirements
for Septage Disposal and other Public Health Activities
Fire Department: Determines Compliance to State and Town Requirements for Personal,
Safety, Property Protection;, i.e. Smoke Detectors, Sprinkler Systems, Etc..
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J ./41 i fo�t�' zc��
Signature of applicant Date'
PLEASE NOTE: ,
COMMENTS:
/D-/7-/f
Reviewed by: Water •'vision Date