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Home My WebLink AboutBLD-20-859 Office Use Only o1.Y``LR O -Permit it t�11� piAmount 90 le%"wonnc..nor`� "eesi4 Permit expires 180 days from " issue date EXPRESS BUILDING PERMIT APPLICATIO E C E I V TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 AUG 14 2019 South Yarmouth, MA 02664 (508) 3/988-2231 Ext. 1261"„xi B: I'Er;..i5 ,010 CONSTRUCTION ADDRESS: og 6# i47 - 1 1 ASSESSOR'S INFORMATION: Mn• Parcel: OWNER: rei /N7e,:..- y/ ksoi nYl"IL' f 2 9 7�/ NAME PRESENT ADDRESS TEL. # lam, �+1,CONTRACTOR: 1'► 'Il,►ci I Pfl1€ z . NAME MAILING ADDRESS TEL.# Xesidential 0 Commercial Est.Cost of Construction$ ' p�p Home Improvement Contractor Lic.# /51 403? Construction Supervisor Lic.# C 5 1 ; Workma}'s Compensation Insurance: (check one) /�I am the homeowner ❑ I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED pprio ... Tent Duration (Fire Retardant Certifi •to 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 Pool fencing *The debris will be disposed of at: 5---&56 CO Location of Facility I declare under penalties of perjury that the statement ein 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 revocation of lic eientmrler3vl:G.L.Ch.268,Section 1. Applicant's Signature: Date: (j 1. r Owners Signature(or attachment) Date: Approved By: '1 - Date: 9�i >47 Building ici designee) Eb' ,tom. uDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents • 1 Congress Street, Suite 100 v 1 Boston, MA 02114-2017 s. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): �r e./ 7/fie /� Address: c9g &' - � ,/ 4aV4 City/State/Zip: Armo,34 ov'L /i11' Phone #: , fZJ F7 2 Are you an employer?Check the appropriate box: Type of project(required): LE I am a employer with employees(full and/or part-time).* 7. New construction 2.2.[..)..airra sole proprietor or partnership and have no employees working for mein —any capacity.[No workers'comp.insurance required.] 8. _ Remodeling 3.0 I am a homeowner doing all 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 property.mY I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.# 13.Q Roof repairs 6.0 We area 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-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.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 under the pains an e Ides of perjury that the information provided above is true and correct. Signature: Date: 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. 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