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Home My WebLink AboutBld-20-001070 Stii.1r _ . ce Use Only I O r wet*.'/ . H Amount LI0PIICTO h„„ r AIJ ti /'; 2tj r ri , Permit expires 180 days from =ems :•"' �/ ;�� , i� .issue date 1:7k. F"`C .. ,i EXPRESS BUILDIN APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 \c• , ri\ Q CONSTRUCTION ADDRESS: l \ \\ \) Ai!, •JCD L'4C..r1✓`/J4 -o ` ASSESSOR'S INFORMATIO \,C\",\ % ' Map: Parcel: `` ` OWNER: •�S LoPRESENT ADki DRESS N �� 6 kb� TEL. # % 'S 10 `\ NAME CONTRACTOR: \(j �1j e__,,rV..._ V::) C,Ar 1r•0 ck.›.. w .1 Cs-va 3 6/ 1 \ NAME J MAILING ADDRESS TEL.# ❑Residential Commercial Est.Cost of Construction$ \o ,0 C Home Improvement Contractor Lic.# \S-CICLA\ Construction Supervisor Lic.# Q2 r)Q-t Workman's Compensation Insurance: (check one) ❑ I am the homeowner//�� ❑ I am the sole proprietor `t�'I have Worker's Compensation Insurance Insurance Company Name: \V'.. "v Worker's Comp.Policy# W`�.�v�16�jS 6\7x be W\110 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofin . #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: '__`la J Cr '. L- ,..---) Location of Facility I declare under penalties of perj 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 o tion of my lic and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: i \ ? h)\\,e-N Owners Signature(or attachment) ' Date: 8/;.3 I Approved By: „..,�[ Date: % Zo, — Building Official(or designee) EMAIL ADDRESS: Zoning District: — Historical District: ❑ Yes 0 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 .e Department oflndustrialAccidents gel= 1 Congress Street, Suite 100 _ = Boston, MA 02114-2017 www.mass.aov/dia 1� + b Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): \ C.�,...�Z..G Address: AO 'ES-Ksc, City/State/Zip: Phone #: t 3 U 7 —\\Ct Are you an employer?Check the appropriate box: Type of project(required): 1. m a employer with — employees(full and/or part-time).* 7. ❑New construction 2.E 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.E I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 9. ❑ Demolition 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ 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. 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 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#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. #: UC--C-C \2, Expiration Date: t'+Zi \`\ 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 de he pains and penalti of perjury that the information provided bove true and correct. Signature: Z1 `ek 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. Other Contact Person: Phone#: einpuihs 4110411M MBA ION 901.30 VII tOisql IOSIaging*eogid uounosi uoflltfl6.H sseuping pus sow ssUnsuo0 O sow° :ol wow puno;jj eptp uonsagbay tap eiopoq Apo esn jervpiampui aoj Nee uons4s03e1i kolleioniepun •• juirAtyri 14inovitivA • z Oki OHO 01 MEIV:LNVO 0001 SNOA.F. 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