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Home My WebLink AboutBld-20-0001148 04,.YA Use Only O - • •H _._ _.__ i aAmount F' Esc rr}} n (('' ! c vz..aw"e,coi AUG 29 2 01 J :;Permit expires 180 days from '- ,�'rr//�� issue date t. BU�I ARTA,1E LS0 By EXPRESS BUILDING ' 'i v ' ' ATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: t)/2 R___44 L(I P Wait t ASSESSOR'S INFORMATION: Map: Parcel: �,,��jI ��--(!'� OWNER: S J��2..( cD 4- 06 F�ADAl CEO r2 Si,v ED�r�C c��,a"'� 'S( t At f'ite.4 NAME PRESENT ADDRESS TEL. # i �g�^ Z C'7/ CONTRACTOR: NAME MAILING ADDRESS TEL.# .Residential 0 Commercial Est.Cost of Construction$2 /P-00. D O Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) AI 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 4780. ' Replacement windows:# Replacement doors: # Roofmg: #of Squares ( X)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (A Replacing like for like Pool fencing *The ebris will be disposed of at: 1'0 t j/J !mug v /k Lfr/0,0 ility I declare under penalties of p .ury 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 o revocation of my se for prosecution under M.G.L.Ch.268,Section 1. 1 A licant's Signature: (+ Date: g`2 q / /1 ners Signature(or attachment) Date: / // Approved By: 1.. ". Date: Building Official(or d gnee EMAIL ADDRESS: 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 0 No r_ The Commonwealth of Massachusetts .c I.---7—* _ ' Department of Industrial Accidents __E.III 1 Congress Street, Suite 100 _- `_ Boston, MA 02114-2017 IV ',.�;�5••y'y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibl Name (Business/Organization/Individual): S► iri2 1 p C C...a Address: d2?- ,bg,,_ 4 City/State/Zip:.Il'J. ��12JkDOWC Phone #: 6 ( 7 L — 8-79 Are you an employer?Chec the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 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 I I.❑ 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. 13.El 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_ 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. #: 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 d hereby cer fy under the pal an penalties of perjury that the information provided above is true and correct. Si_ (,I�afore: � - Date: , — 21 " l 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 CIerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: -7? M tA* f r Pq y LOA/c.e--ra_ik) , c uu; //o(h`A); 7) Th w A � v AFTS-a_ A 2(0 RECEIVELii AUG 29 201 BUILDING DEPARTMENT