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Home My WebLink AboutBld-20-00846 Office Use Only iir:of'BAR .. : r„! O: Permit �j'� o/l Il•'� y Amount L7�/ y MATT M s. k'1 ;"� _ `*oRmAno" ECd.' Permit expires 180 days from l' '#)i''. issue date ED EXPRESS BUILDING PERMIT APPLICATIO C E V TOWN OF YARMOUTH Yarmouth Building Department I 1146 Route 28 AUG 14 20/9 South Yarmouth, MA 02664 L,�------w--- Bul 1 (508) 398-2231 Ext. 1261 By. CONSTRUCTION ADDRESS: q 2.. Pti YtA_I$ NI V e ASSESSOR'S INFORMATION: Map: Parcel: OWNER: SvcA,J II. F'egwc.v RZ pt./1645 i)i ivC 3-641 -2W 2310 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# yl Residential 0 Commercial Est.Cost of Construction$ A5.00 . C30 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: .9.41 Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 2- 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: /ARM D GI TH 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ass-_..< Date: s'``Lf'I Owners Signature(or attachment) Date: g ' I —I? Approved By:_ Date: // 7 Building Offf ' (o sig � � nee) EMAIL RESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ‘tzar Sys,, www.mass aov/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): SU54 xi 1 Q AN co Address: ?2_ Pti yL .is .1>R cve City/State/Zip: Sourrt xl2m�v�ff M� 6244f Phone #: s'p8- Ziff- Z3 'a 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 2E1 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..I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on mYP property.e I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E 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-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.El Roof repairs 6.❑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#I 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 and penalties of perjury that the information provided above is true and correct. Sianature:��t,c� Date: f Phone#: 5 I 2 51/. Z390 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#: