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Home My WebLink AboutBld-20-001127 •i ice Use Only /� /� C s i" O . - .$ Amount /CAry gt y 1 %MATT M CS t tt / ` ,�y� "''^+.avid E�"d A1J U `///a�!/�jy�� 'Permit expires 180 days from 1:, �F R N!FN issue date ; EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Li-i .es 4. 1N'L'w.o kW\ R.ci O 2A4 1uvv tl.41 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: r...,(VY) L'- Leptis 3,4-yyves... (1 i ) aia - 3 SAD NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.#Residential 0 Commercial Est.Cost of Construction$ 6 700`-h (/ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm 's Compensation Insurance: (check one) ` I am the homeowner 0 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 Repl cement windows:# i I Replacement doors: # 3 +4 6/ode. Roofing: #of Squares 02 0/ 5 Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing S The debris will be disposed of at: "'?'LO*-Y1 4 fekn.�g`,`,-�-A 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: .Owners Signature(or attachment) k i 6.. ` 'Bvy„ Date: Approved By: '49:E ' � Date: 0 ./��-.„ Building 0.e• .i (or tgn EMAIL ,L B�SS: Zoning District: Historical District: ❑ 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 - � Department of Industrial Accidents _nt11. 1 Congress Street, Suite 100 _'ti_ Boston, MA 02114-2017 VM;;S••`'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly 2/ 1 Name (Business/Organization/Individual):1../,�,-3,,v,,,,i, 1 '0J Address: Li y 3 „¢.b4- ter~ L.ci. _ 1 jos,/ 1,04-,, i,\ City/State/Zip: Phone-#: Are you an employer?Check the appropriate box: Type of project(required): I.❑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. am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp.insurance required.] 4.1] I am a homeowner and will be hiring contractors to conduct all work on myproperty. 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.❑Plumbing repairs or additions 5.❑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. Roof repairs 6.0 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. tContractors 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 perjury that the information provided above is true and correct. e1 Sianattu, l i s Date: /- 1 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: