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Home My WebLink Aboutbld-20-001288 Office Use Only 01..YRRi.�r Permit# i • •:0�. l.y y Amount /O D_ f =_ °`°roan°"'E,d' Permit expires 180 days from *;;:----. ;issue date EXPRESS BUILDING PERMIT APPLICAT C E i ��' .• TOWN OF YARMOUTH I 7 V .. Yarmouth Building Department 1146 Route 28 E CEP - 9 2019_ j South Yarmouth, MA 02664 B i Np�r r�A trlu;E n� P (508) 398-2231 Ext. 1261c�/-� • CONSTRUCTION ADDRESS: 7 4r 474.(ej l,,t /-,/,yG,`, /esi 4 02 Of ASSESSOR'S INFORMATION: / Map: Parcel: OWNER: j5 .;il, S-f'.. % `l7/f;y=U ik e �•A/,• .... 7TTI, 2✓2_,, NAME PRESENT ADDRESS L. # CONTRACTOR: NAME MAILING ADDRESS TEL.# l_f'1�esidential 0 Commercial Est.Cost of Construction$ 74.cr=v `1/ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman..Compensation Insurance: (check one) am the homeowner 0 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 Replacement windows:#/r 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 /.7c�i .r-74-P� / 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 lic se and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature.?,' ' . Date: / / ( l Owners Signature(or attachment) g/'� - � ..7 Date: `��ji'% Approved By: /�.,. Date: 7 -77 Buil . • (or designee) E RESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual):f(,,,,_./ 5 Address: f` ';�� `Sj p City/State/Zip: Svc��l(rGr.7,� /i 1 'Cj Phone #: Are you an employer?Check the appropriate box: Type of project(required): LEI 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 a. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.1Z-ram 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 roPenY• I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 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.E Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sianature:� Date: 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. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: