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Home My WebLink AboutBld-20-001080 (2) ;YRR 1 Office Use Only _2,.! t0 j Permit# er O. ii . H Amount V MATTACM ESE *.....00 d ''Permit expires 180 days from 2--t./J D issue date B EXPRESS BUILDING PERMIT APPLICATIOl 1 R ECE1VFD TOWN OF YARMOUTH Yarmouth Building De artment 1146 Route 28 s AUG ?6 2h19 South Yarmouth, MA 02664 (508) 398-2231 Eft. 1261 �.. cJ CONSTRUCTION ADDRESS: i W 0 ehad.S�S S o� ASSESSOR'S INFORMATION: �/� Map: (� Parcel: �/ OWNER: ►' \� �, 1�.+4� O'Y6 ).S S� a �� I 5O 6 O'� 10U NAME J PRESENT ADDRESS TEL. # CONTRACTOR: je(l.� NAME MAILING ADDRESS L.# ttResidential ❑Commercial Est.Cost of Construction$ 7 Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) 4 I am the homeowner ❑ I am the sole proprietor ❑ 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 WO Old Kings Highway/Historic Dist. (}()Replacing like for like Pool fencing *The debris will be disposed of at: t _ k-VLS f 10.-V\ b! �C C, 1v- Location of Facility I declare under penalties of perjury that the nts 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 revoc of m i ense and for prosecution under M.G.L.Ch.268,Section 1. / � / 4X, Applicant's Signature: Date: Owners Signature(or attachment) Date: g Approved By: Date: \ Building Official(or designee) L ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No \ The Commonwealth of Massachusetts (I Department of Industrial Accidents i 1 Congress Street, Suite 100 .3 Boston, MA 02114-2017 0,M,.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 (),/\+ . ei' Address: ( O '(e.r.,,,s,A-s-t- City/State/Zip: S. VIA1,-.O ) m .c�°� Phone #: 5-0 3��^ (/Of Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. _New construction 2.— I am a sole proprietor or partnership and have no employees working for me in g 8. — Remodeling an capacity.[No workers'comp.insurance required.] — 3. I am a homeowner doing all work myself. 9. Demolition y [No workers'comp.insurance required.]` — X 4. I am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 — Building addition P property. ensure that all contractors either have workers'compensation insurance or are sole 11.0 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. I3.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.= 6.E 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-conttactors 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. 4: 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 r un r the pqi and nalties of perjury that the information provided bove is true and correct. x A Sianatur . Date: O ,a7G�g I Phone 4: —36 7 ` Q7O 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#: