The URL can be used to link to this page

Home My WebLink AboutBLD-19-003442 -+ - -- - Office Use Only ol''r'9k s Oc. 5 Permit# .n • O4,,,,,,, H i •. Amount_F4= i I Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATIME C E I V E L TOWN OF YARMOUTH Yarmouth Building Department DEC 06 2016 1146 Route 28 __ RT_ South Yarmouth, MA 02664 BIIILDINCG DEPAMCNT 2 (508) 398-2231 Ext., 1261 BY CONSTRUCTION ADDRESS: 11 C R C tk CA % 'rex., S .1 u4\ \A e a6(9 ASSESSOR'S INFORMATION: • Map: Parcel: OWNER:Ea Wo-r-el CI o-e It 11 1p B-e.i.cer.‘ gi. 5.b5.11 6 - 1 lit NAME PRESENT ADDRESS TEL # CONTRACTOR: NAME MAILING ADDRESS TEL# Residential 0 Commercial Est Cost of Construction$ 5;(p 1 Home Improvement Contractor Lie.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) • ALI 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 Peel fencing SVCCK *The debris will be disposed of at 10..'Yt10'TIN, D WA Q Location of Facility I declare under penalties of perjury that the statemdnts 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 r revoc 'on. my lice .e and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signauve Date: \-).. .1\��y� Owners Signature(or aft ent) SPA Vel /a& Date: 1 6ry Q Approved By: J / - ,G+/a, Date: /J C —/F 4.7 ding Official(or designee) EMAIL ADDRESS: AZoning Disrict: M �� Historical District: 0 Yes 4'No Flood Plain Zone: 0 Yes 0 No `6 L / Water Resource Protectio District: Within 100 R of Wetlands: J 0 Yes Lo 0 Yes 0 No __ The Commonwealth of Massachusetts 7 �h / Department of Industrial Accidents i _ I_ . =she= '. 1 Congress Street, Suite 100 F. F1__ Boston, MA 02114-2017 �t� 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): fif) t Fe„ c.e coin P&vt`{ Address: In,Ae, ItCK City/State/Zip: 1wn.inotat,' • 611,41 Phone #: Are you an employer?Check the appropriate box: 1 Type of project(required): 1.0 I am a employer with employees(full and/or part-time).' 7. 0 New construction 2.0 l am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]% 9. ❑Demolition OMam a homeowner and will be hiring contractors to conduct all work on mY PP�%Y•ro I w11 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietor with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contactor and I have hired the sub-contactors listed on the attached sheet 13.0 Roof repair These sub-contactors 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.❑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 contractors 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. 1 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 herebyycerttiify�u dererthe and penalties of perjury that the information provided abo e is true and correct. Si?natura�-C N Date: I all ii Phone#:(563-77(0-`j-7Y ? 11 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#: I \ m Co g X \ t � e � $ ° E m 05 I ibe N a N � � E 1 N I f; \ n 2 t. cv -e-P1 1 . i . iii i I i ri , ita% .,z, .1%‘ 44t2 1 1 I's i O 6 • I dill IL P p ' s �� W av c n O 1;1 s1 11111 c14 , EC0 o illinti i g II y § $ 3 :1' to G \ Q/ Nil ag< E—i g c z c sci c4 c o Do ; a IiiIi\ t = r r W W z i 1. I it; • 1 € `� S sig . i . 11110=0 l( C 6 . . it WI