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HomeMy WebLinkAboutBld-20-911 OF.1r Office Use Only 9 two _ o 48,41 . y Amount A MAT...• f5E �w�o.t�o"' d Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 , (508) 398-2231 Ext.� 1261 `p1 CONSTRUCTION ADDRESS: L m cZ Po& 2.DO^- ) \\M iVU ASSESSOR'S INFORivLATION: Map: j Parcel: (� (��, \�' I^ ]n OWNER: Jb5 F ° 4 L3O�C_ t ` 3 L0;Lri ( (IJ EE105Jaq 5Cx151l�3tf?S NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ' ❑Commercial Est.Cost of Constructio 4►46 00)&w Home Improvement Contractor Lic.# Construction Supervisor L. . "" 'I `" ' , I Workman>Compensation Insurance: (check one) E�'I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation In ur. ce 41.47192n Insurance Company Name: Worker's Comp.Polic . nl �J Y-'AR rMENT WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares LZ ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: VA A44)14 Location of Facility I declare under penalties of perj' 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 r• ation of , license an.,i irosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: J . _ 4 Date: 51 aS ii 9 /Owners Signature(or attachment) Date: 5 kS'l` Approved B : / i pp y �/ Date: Burl.t' ffi .. (or d- ignee) E DRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes n No f The Commonwealth of Massachusetts ` 1Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ''''1„�5�•,i'.� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly ✓Name (Business/Organization/Individual): T© Pp C Q IV F'`— Address: 1at rnQ 4`z Moor._ IQ: y3 R rna o City/State/Zip:9 N mbua IN)R Cja1..0-13 Phone #: S "1 t_i31, Are you an employer?Check the appropriate box: Type of project(required): 1.❑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. E Remodeling y capacity.[No workers'comp.insurance required.] — 9. _ Demolition 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 10 E 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.E Electrical repairs or additions proprietors with no employees. 12.]Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oOf repairs These sub-contractors have employees and have workers'comp.insurance.: 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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. 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. do hereby certify der the p ',is and pen ties of perjury that the information provided above is true and correct. Signature: C., Date: 5 It9 Phone#: 5P( 1 (p 3 is-70 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*: edr-1 \ V), jAOY1A. , A MI � Coen ODQ aTe re,s ‘deng+s tq MI(ror3rcc7 '� P-d , k),) . `lftoc44-k\ and �i �F e� al� �' i rrt2 n 3-ce) Ovs iwrna rQs[c1-ence dice q)01\al,Tke( “Lna-0Qd-co a_s �--c�e c1pe