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Home My WebLink AboutBld-20-2018 Office Use Only 3 Z OY R �- • Permit# O *'1 ':Amount /OD •�` MATT M LS - - =Permit expires 180 days from -= ...• -ao D i r issue date EXPRESS BUILDING PERMIT APPLICATION tli, I ' jii TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 CIO- Li 31/ South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: `-(0 SW t ?WO k f- �• Y U,Ynitu W iW 0110 I ✓ ASSESSOR'S INFORMATION: �.1IA Map: / Parcel: 7 /'��( L OWNER: Ln _1 1 M 1i C \t PUY•11�C . �'lp SWi} l-UUk )lt _SO U Z� NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# ❑Residential 0 Commercial Est.Cost of Construction$ 7.U V G �V L— Home Imp vement Contractor Lic.# Construction Supervisor Lic.# Workm s Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor 0 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 213 Replacement windows:# 3 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: 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: Date: MCA 1,VA JUItull � Owners Signature(or attachment) Date: Approved By: / �; Date: 'U -. /0 /4 Building Official(or designee) EMAIL ADD -SS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No ', The Commonwealth of Massachusetts If _ , ,_ Department oflndustrialAccidents v�Al- 1 Congress Street, Suite 100 v- Boston, MA 02114-20I7 --, — ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): v J 1 n A- IA r-CIli XL RIM Address: 140 S w\ c*- b1(✓0 k Wu( t/ City/State/Zip: -S wY titi• O2&' hone #: JO6- 2i( — .4 2.3 .7-- Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. E New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling y capacity.[No workers'comp.insurance required.] 3. '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 roPm'•e I will I O Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs • These sub-contractors have employees and have workers'comp.insurance.= ��`y 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 'wrt r S(� T W� 6.{: 152,§1(4),and we have no employees. [No workers'comp. insurance required.] �r 111a0W J S *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. t-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 c tzfylijk uder the pains and penalties of perjury that the information provided above is true and correct. Signature: O Date: 1 0/0/ ) U I 19Phone#: 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#: