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Home My WebLink AboutBLD-19-3412 Y Office Use Only A vFAR 4 51 • Amount 7 '_ �- GEC 4 018 Permit expires 180 days from s I issue date f' Ii ' i.. "jEPARTMENT 9y. EXPRESS BUILDING PE ' 'PLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 ,,II (50,8) 398-2231 Ext. 1261 ip CONSTRUCTION ADDRESS: Mi&l*icMte DP-It/ , So ww YAtDu7 a tend 0266 q ASSESSOR'S INFORMATION: Map: n Parcel: /77 OWNER: NI COW A 6171 V b Nie4411NOfAC& Da- • $$gkafo c4#1- 50 I-375-5b9-z. NAME PRESENT ADDRESS TEL # • CONTRACTOR: IY/!. NAME. MAILING ADDRESS TEL.# C 0 Residential 0 Commercial . Est Cost of Construction$ 2-ISO 0 Home Improvement Contractor Lia# Construction Supervisor Lie.# 1 Workman's Compensation Insurance: (check one) $ I am the homeowner 0 I ant 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:# 7 Replacement doors: # Rooting: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/HistoriccDisst. ( )Replacing like for like Pool fencing "The debris will be disposed of at: YAP •,(2617f't 7bttwM Du pi P Location of Facility I declare under penalties of perjury that the statements herein contained are true andcorrect to the best of my knowledge and belief. I understand that any false answer(s) will be just cause f. . .. .r revocation of m (cense and for ins ecution under M.G.L.Ch.268,Section 1. / ��a. 2/ Applicant's :tgnature:_ —'�—eatuLT r. Date: I 15 Owren.ignature(ora•/� �' Date: —i Q Approve. : /��.��ra�� Daze: /Z — y U :uildin•• ''. design-- 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 1 ��_ _ / ( Department oflndustrialAccidents nel_ 1 Congress Street,Suite 100 _; E Boston,M4 02114-2017 , � www.mass cov/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): MI e,144- t. P,&77 t'I Address: 6 AlIMcIra-eca otn',c City/State/Zip:S. yam our IPL '1Yr 026E4 Phone #: 50C<— 3 7S --56 2 Are you an employer?Check the appropriate 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 any capacity.[No workers'comp.insurance required.] 3.1141I am a homeowner doingall work myself. t 9. Demolition y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property.Prt7 I 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 5.01 am a general contractor and I 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 MGL c. 14.0 Other 152,§I(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 such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contactors 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 free 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 DR for insurance coverage verification. I do hereby certify under the pain and penalties of perjury that the information provided above is true and correct. Signature: Date: II-- Phone g: Phone#: 508 - S7 -56 'f2 Official use only. Do not write in this area,to be completed by city or town off ciaL City or Town: Permit/License if- Issuing 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#: