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Home My WebLink AboutBLD-19-003331 i Office Use Only Os H Amount -1 c' Permit expires 180 days from = 'issue date e EXPRESS BUILDING PERMIT APPLI ' .A QNE I V E D TOWN OF YARMOUTH Yarmouth Building Department NOV 3 0 20161 1146 Route 28 South Yarmouth,MA 02664 8 ,', .,�EPARTt ,4 67.) (508) 398-2231 Ext. 1261 4 .51c-ii CONSTRUCTION ADDRESS: 4Ij tf'{ L q. ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: lzA- 4-, 51-.iomichra.✓un5 6 51u,4�,,� 5b 373 . 7570 NAME PRESENT ADDRESS / TEL. if couTRAcroR: ilic- �J , 16r S;!/CI c, %.n•�-/t-t/ �6�-�G�;jYy� NAME / MAILING ADDRESS TEL.if RResideatial 0 CommercialEst.Cost of Construction S Idea Home Improvement Contractor Lie.# 1' V 77 17 7//s-- Construction Supervisor Lir# /or-I27 Workman's Compensation Insurance: (check one) 3/2`/"'" i�/// 9/CJ ❑ 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 Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares elf ( \Cs/Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at „.fel 6Ii/ -T-ini A-- Location of Facility 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 a on of my license and for prosecution under MGL Ch.268,Section 1. _ Applicant's Signature: " ,../� Date: I/P /ter' X Owners Signature(o chment A . / _.. „drar iii A ,ate: ,�°� Approved By: ' —/ e Date: /!/-S°%P/ -lid.'.• a inial(or deli:(et) Al EMAIL ADDRESS: 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 •— The Commonwealth of Massachusetts _ Rill= Department of Industrial Accidents ==al= 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): J� (, fiene ye Address: /o r City/State/Zip: y1-,,,r cc- /tfr 4//J Phone#: C°i"3 661—i It An you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. New construction 2.E612 am a sole proprietor or partnership and have no employees working for me in T"any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling 3.01 am a homeowner doing all workmyself 9. ❑Demolition (No workers'comp.insurance required]t 4. I am a homeowner and will be hiring 10 ❑ Building addition ❑ contractors to conduct all work on my property. I will , 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.❑I am a general contractor and I have hired the sub-contactors listed on the attached sheet Thesesub-contractors have employees and have workers'comp.insurance.? 13. Roof repairs 6.❑We are a corporation and in officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees. [No workers'comp.insurance required] *Any applicant that checla box#1 must also 511 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 coot-actors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stare 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 wedjob site irtformarion. 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 un r the pains and penalties of perjury that the information provided above is true and correct Signature: � t%," Date: Phone#: Co vw_ 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. Cityfl'own Clerk 4. EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone :