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Home My WebLink AboutBld-20-000915 qA se Only Zret ��•Y ermit# r c* C: � � (0 . �M'1• H, Amount - MATT Ptf3 �' `R°*,,,�f°�era.' i`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 • CONSTRUCTION ADDRESS: ( ,,") trite.fivt ASSESSOR'S INFORMATION: Map: Why,Parcel: OWNER: 5) AOS ( L 5bpf— 3 lq .2..10 NAME PRESENT ADDR TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# C Residential ❑Commercial Est.Cost of Construction$ 412``"' Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workmat's Compensation Insurance: (check one) C{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 Replacement windows:# Replacement doors: # I 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: Location of Facility I declare under penalties of perjury that e st ments here. 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 revoc on icense for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or a chment) Date: Approved By: Date: �� Building Official esi EMAIL ADDRESS' Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No cRECEIVED ! Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No 3 1t11° 1 pi,) PARTM I'`� The Commonwealth of Massachusetts _ Department of Industrial Accidents _ Al 1 Congress Street, Suite 100 Pf_ Boston, MA 02114-2017 11- .s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): d4vl, ,Sys Address: C (/d L01,,-e__ City/State/Zip: Oki 44-ci 7y Phone #: .5c0F Y 62p 0 Are you an employer?Check the appropriate ppro riate box: Type of project(required): i.E1 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. ZiRemodeling any capacity.[No workers'comp.insurance required.] E 9. ❑ Demolition 3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 E Building addition 4.0 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.Q 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. I4.❑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 certi un tl ins and penalties of perjury that the information provided above is true and correct. Signature: Date: 10/2et `f Phone#: Re 3 Cabo 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#: