HomeMy WebLinkAboutBld-20-001456 --Y- Office Use Only
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:Permit expires 180 days from
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EXPRESS BUILDING PERMIT APPLICATION , , ,,�.
TOWN OF YARMOUTHi. '"
Yarmouth Building Department
1146 Route 28 ' , SEA' 1 (' ' I {
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: '3 i •> . c r- a .) 7 x
ASSESSOR'S INFORMATION:
4i>
Map: ParcelOER: 2e'
RESENT ADDRESS TEL. #
CONTRACTOR:
N MAILING ADDRESS TEL.#
esidential ❑Commercial Est.Cost of Construction$ 2, �-G'r7 is p
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workm 's Compensation Insurance: (check one)
cf I am the homeowner 0 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
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: "9 l v/"b
Location of Facility
I declare under penalties of perjury that the statements herein contained are 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 f rosecu' er i .L.Ch.268,Section 1.
Applicant's Signature: f V Date: 9r7/4/,/
Owners Signature(or attachment) Date:
Approved By: v -- Date: -1 —16 --1
Building Official(or designee EMAIL ADDRESS:
Zoning District:
Historical District: 0 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
r _jiii.� /. Department of Industrial Accidents
"lel= 1 Congress Street, Suite 100
_ `- ` Boston, MA 02114-2017 vi
^M�; 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):
Address: (7,r ,,e/o--,, // 4,7
City/State/Zip: wf 0, Phone #: 101 6 74'if/2 S
Are you an employer?Ch k the appropriate box:
Type of project(required):
1.0 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 8. remodeling
any capacity.[No workers'comp.insurance required.]
3.lam a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. Ell Demolition
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.
12.0 Plumbing repairs or additions
5.11 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. 13.0 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#1 must also fill out the section below showing their workers'compensation policy information.
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 per'ury th t the information provided above is true and correct
6.
Signature: ) `�� Date: ��1
Phone#: Fc2 pj fr rp- Az g
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#: