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HomeMy WebLinkAboutBLD-20-001131 x-. �— Office Use Only - ��° `�4e- • - olto-off //= / C, O . - • . Y: Amount s `-F` .Uri r « ' `= ,'`°*•�*�� spa' Permit expires 180 days from ,-- 4-e,14-e-( 71 issue date EXPRESS BUILDING PERMIT APPLICATION------------:---,-- ' TOWN OF YARMOUTH C, F i V xt Yarmouth Building Departmentii(A) 1146 Route 28 s i)r .r`1 201?1 , South Yarmouth, MA 02664 � (508) 398-2231 Ext. 1261 ��'E}'A . : CONSTRUCTION ADDRESS: +3 letfrj.Z&-i? 0- (/: i' L ASSESSOR'S INFORMATION: Map: Parcel: �� p /� )1WNER: Mai}i c\ 1 rt. S 22, e~ �%�'(. ( 3/ 69 5 /`7` NAME PRESENT ADDRESS TEL. CONTRACTOR: NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ V ,7 00 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) Y.I 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 '3 )" Replacement windows:# 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:, M.71°1 �v( 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: v Owners Signature(or a hmeat), 1eZ Date: �r Approved By: Date: oP " "2T - / g Official(or designee) 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 . The Commonwealth of Massachusetts _ _ l Department oflndustrialAccidents LA= 1 Congress Street, Suite 100 •_ex._ Boston, MA 02114-2017 to;. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly )Ime (Business/Organization/Individual): IA Address: 7Se/;/,,r,43 ,-AT City/State/Zip: ��° q7 /1m %( Phone #:6©5 3 60) `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. E Remodeling any capacity.[No workers'comp.insurance required.] 3161 am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp.insurance required.]' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 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.❑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 do h S hereby certify under the pains and penalties of perjury that the information provided above is true and correct. tture: .AS f c2q/Wl"! �/ r 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#: