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Home My WebLink AboutBLD-19-3332 Y Ow.ce Use Only 3 •f • •z• 4. it- • . — /go033= Z _N I .S - Amount s �Cdi - -- - Permit ex• pires 180 days from • issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 2 s-/ 7s-c- South Yarmouth,MA 02664 • //)� �j (508) 398-223122Ext. 1261 / /� J`� �i . CONSTRUCTION ADDRESS: if/��/t�4p -(.56A a t f 14'I,�(6- o, / ( � t..---- ASSESSOR'S —ASSESSOR'S INFORMATION: /v/�/� /J r Map: ' / CA/del(' / Parcel: (� G OWNER: i V`/C c 1° 901 cA/ el(' 6.08--- a(00-09 I 1' NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.## 0 Residential 0 Commercial Est.Cost of Construction$ jai( QCO 0 ,1.----- Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ 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 4ac . ' /Replacement windows:# 6 t/ Replacement doors: # l L.,...-- Roofing: Roofing: #of Squares , /9"-" 4/1 )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 Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my lmowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my `cense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: /Owners Signature(or attachment) ,ti Date: /r/3d/It V Approved By: Date: Building Official(o 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 r _ The Commonwealth of Massachusetts l 1eni it Department of Industrial Accidents ?9(uA/76A)_=,e1Congress Street, Suite 100A U % s#5. Boston, MA 02114-2017 J n / �.� www.mass.gov/din / �/j/fl/1S-� ((�o &CY Workers' Compensation Insurance Affidavit: Builders/Contractors/El ctricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/ rganization/lndividual): Ait 4 I 9 0 Al ✓ Addres: K0 -GC /(3 - SEA lel efLi Ur ,dir, oxiti City/State/Zip: W - Phone #: i.)-‘m(- 3 (on- Oq 1 9 Are you an employer?Check the ap opriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling 3.1aa capacity.[No workers'comp.insurance required.] am a homeowner doing all work mysel£[No workers'comp.insurance required.]* 9. 0 Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑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. 13.D 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 e. 14.0 Other 152,$1(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 and then hire outside contactors must submit a new affidavit indicating suck *Contractors 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.Lb.#: 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 certi • - • e r„ .: , , 'a , perjury he information provided above is true and correct Sign. Br !/ - Date: if 36 / , L.------ Phone#: 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,§250(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,MOL 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 contacting 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 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 6 R _ECEIVED CIAAtebt NOV 30 2018+ f3GILDWG DEPARTMENT Hv A n Macw C7Avd lv/eJecA _ eeh str� c� o -C flyetly leg fi -70.7e_S @Ayr e u otrffAce o / C- (i /y M