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Home My WebLink AboutBLD-19-3880 ' . Y ice Use Only t; i C', Ot c •insito - % ccs - `Permit expires 180 days from • ,issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 JAN 0 2 2019 I South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 a = DENARr rnU q gob0 � -NQ CONSTRUCTION ADDRESS: 42.( ASSESSOR'S INFORMATION: • Map: I. Paar+cel: 1 1 OWNER: �� Lii -�* .i . X -i pL C c-l-t 1 obsce5ii se 7E5 NAME �r,,Iy� . PRESEN ADDRESS -fj TEL # CONTRACTOR:'V•F.iL dt-•�$(�� r'02493 � 2 NAME MAILING ADDRESS 024 / TEL# 14 idential 0 Commercial Est Cost of Construction$ . /{f oDe) Home Improvement Contractor Lia# /07 36?' Construction Supervisor Lie.# 04177 // Workman' Compensation Insurance: (check the) / zeI am the homeowner / 0 I am the sole proprietor (91 have Worker's Compensation Insurance Insurance Company Name: tAkisk Caved Worker's Comp.Policy#. J tL4)C b 4j j Q 29 WORK TO BE PERFORMED • Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares I I ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic`` Dist.y ( )Replacing like for like /Pool fencing'[/ / *The debris will be disposed of at :l V lb at Q da{L * 7 erC/ 64710-mac Location of Facility I declare under penalties of perjury at the stateme .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 deni r o anon o y lic: e and for prosecution under MG.L Ch.268,Section 1. Applicant's Signature: / 41 Date: I/o2/)9 Owners Signature(or attachment) „ / Date: Approved By: % / AV Date: B ' : %'.:tial(or designee) ai AIL ADDRESS: • Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes C No Water Resource Protection District: Within 100 R of Wetlands: • 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts _�' Department of Industrial Accidents 7ele 1 Congress Street, Suite 100 Boston, M4 02114-2017 %,-w:„ccor 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):n� i C1.1) ii 344 4r/1/5" `c Address: / 7 "E"A l ary4 41 City/State/Zip: 47fe Phone#: $'5'67 6763 Are yo an employer?Check the appropriate box: Type of project(required): 1. I am a employer with .1— employees(full and/or part-time).•. 7. 0 New construction 2.01 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 work myself t 9. ❑ Demolition ❑ y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 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-contractors listed on the attached sheet rsi 13. Roof rep a - These sub-contractors have employees and have workers'comp.insurance.* /d/ • 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other �d /H t 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-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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /q/Q51 ( Zc/42i Policy#or Self-ins.Lic.#: J.&JL Ty' 9;19 Expiration Date: q/,3/JQ Job Site Address: 9 /`Ofa�/T�I )f/.a-c (fj1 City/state/Zip: 02673 Attach a copy of the workers' compensation policy decla ation 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 c der tle pai s and penalties of perjury that the information provided is true and correct. Signature: 4 (/ .n Date: l a//l Phone#: 111 / JD?' 867 6'76'S 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#: