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Home My WebLink AboutBLD-20-2105 Q'f•Y11R t/f 14 O. 1l''/� ? . H Amount 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: 1 O 7 R o p�� S . \/ -09"CI ASSESSOR'S INFORMATION: / Map: Parcel: OWNER: .3-re h c2N5 /WA:4 . 5 \/1ls'.ta..G.P►^ / - Li 07..' c-7,50 NAME I PRESENT ADDRESS TEL. # CONTRACTOR: -3 I.Gy► C e.Ic 6/ -✓L'(,}Teie,-► Or°--c— /as -77Y-1/3 C1c f NAME MAILING 1�)DRES ix, TEL.# 46,❑Residential 190Commercial ES..`Cfit4onstruction$ /.C1O Home Improvement Contractor Lic.# /537Ss Construction Supervisor Lic.# (''s —0S77/& Workman's Compensation Insurance: ck one) D I am the homeowner Si 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:# / 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: f Vv,.. 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�on of my license and for pro cuti n under M.G.L.Ch.268,Section I. Applicant's Signature: J � —of_.- IP Date: 0//6"/ Owners Signature(or attachment ,`._►.— Date: /0— /6-/1 Approved By: Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: f Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No . . r 1/5e8K . . Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes ❑ No OCT e 2019 I I BUILDING D PARINI :Nl" 9y' - Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons til4n visor 4 CS-057712 . pares: 03/30/2020 (10. 1 .3 STEVEN D COLE II 44, 61 EVERGREII ' NS MIL. MARSTO ()1 .j3cst Commissioner a.- The Commonwealth of Massachusetts 717 Department oflndustrialAccidents // "e= 1 Congress Street, Suite 100 =111: Boston, MA 02114-2017 "•` www.mass aov/dia 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): it, 4--) Address: Gl �'ke.tc.r, - -, (�f�__- City/State/Zip: i - , �/5 ��.C one #: 77(1—f/7.—Ox Are you a toyer?Check the appropriate box: Type of project(required): 1. am a employer with 6) employees(full and/or part-time).* 7. 0 New construction 2.0 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. I am a homeowner doingall work myself. t 9. ❑ Demolition ❑ y [No workers'comp.insurance required.] 4.❑I am my ProPertY•a homeowner and will be hiring contractors to conduct all work on 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. R f 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. 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 pe aloes of perjury that the information provided above is true and correct. Signature: Date: /04//9 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#: