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HomeMy WebLinkAboutBld-20-001803 .pi•.Y44 . .... .., C 1Permit# +' O y i Amount 50 MATTA M [SE -_ `"'°°'"°1 E`'d' Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 OCT 02 2U1 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CJ cY CONSTRUCTION ADDRESS: g ��,2i-771 //kr714 ASSESSOR'S INFORMATION: �l ! Raba"- Map: / Parcel: `> ,�^J✓�1✓ 7(, 22 - OWNER: Rab5a t'= l�L/�jl/ b7 rl/tt �L /✓�l i�� (� CG�//-36 /- 9/ NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# 7esidential ❑Commercial Est.Cost of Construction$ pl)0 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) XI 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 2._,j ( t---Trelnove existing* (max.2 layers) Insulation )4118`` ldngs Highway/Historic Dist. ( )Replacing like for like Pool fencing S,19 i D Jp/Lizr-- *The debris will be disposed of at: Location of Facility I declare under penalties of perju 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• revo°.tion of m lice .-.: d for p ution under M.G.L.Ch.268,Section 1. Applicant's Signature: / _ 1 L��, - f i Date: U°G7` Z�� w Owners Signature(or attachment) , / �/'/: Date: 2. OC/ 70/7 Approved By: �t /(` — Date: AO—2 �ff Building Offici or d gnee) EN ono DRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes E. No `' '� The Commonwealth of Massachusetts e 1 2 Department oflndustrialAccidents I 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,� www.mass.go v/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): te.612 , e ,4L.__. Address: 6-7 Ate . -/ ,, CiCity/State/Zip: 6 .76. €.S'�';e tY P:SOci W ©c� d 264 Li' Phone #: - 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 2.1]I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling a 9. El Demolition y capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 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.❑Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs These sub-contractors have employees and have workers'comp. insurance.: 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. 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 certi,. ..-r the pains a enalties rjury hat the information provided above is true and correct. Signature: IIIDate: 2. 0 2' V Phone 4: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 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#: