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Permit expires 180 days from =
:- = issue date
EXPRESS BUILDING PERMIT APPLICA ' r }
TOWN OF YARMOUTH �_..
Yarmouth Building Department
1146 Route 28 AUG 2 201�
South Yarmouth, MA 02664 ,- i a
(508) 398-2231 Ext. 1261 10 �EaARTnn`
CONSTRUCTION ADDRESS:X` /L..f'/Tim/AI 46(YeAr,iis.#N cp
ASSESSOR'S INFORMATION:
Map: Parcel:
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AME )E SENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
'Residential ❑Commercial Est.Cost of Construction Si\ yGfJc% o e.
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
' fi ►Yam 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 Replacement windows:# Replacement doors: #
Roofing: #of Squares ,7e, ( Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: /,, J " I L�/H,AS .
�iv ation 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:
Owners Signa a(or atta m t) Date:
Approved By: Date:
Building Offici igne EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
The Commonwealth of Massachusetts
=iiiiitiD-1=
Department oflndustrialAccidents
_ ' 1 Congress Street, Suite 100
IT- Boston, MA 02114-2017
s�;5.•` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
T LED WITH HE PERMITTING AUTHORITY.
Applicant Information /c14,11XQ ,r/L/1/�A) Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
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. ❑New construction
2.E1 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
bi/
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
5.❑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.
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 an
o hereby c der the pains a penalties of perjury that the information provided above is true and correct.
•
i�4atur -iZ��,,, �..e � .
Date: ,,r✓jr✓��%
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#: