HomeMy WebLinkAboutBld-20-001914 Office Use Only
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'� MATTAIM CSE 4,. -
=__ t twat.**eTd,'' <`Permit expires 180 days from
c- ::- issue date
EXPRESS BUILDING PERMIT APPLICAT fIKCEIVED
TOWN OF YARMOUTH
Yarmouth Building Department OCT 08 2019
1146 Route 28
South Yarmouth, MA 02664 gN7t NA R T ,
BY
(508) 398-2231^EExt. 1261
CONSTRUCTION ADDRESS: C.) \D \\ -��'f-1J1�1C x j) �'-m- Eke 1\ 1 1
ASSESSOR'S INFORMATION:
C Map: \ Parcel:
OWNER: \�‘a �l V 1 )t�1 RC' ,A WC 'C O e '' b V
NAME PRESENT ADDRESS TEL. # �T
CONTRACTOR:
K
NAME MAILING ADDRESS TEL.#
esidential 0 Commercial Est.Cost of Construction$Q 'j0 C)G•C)
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
Nam the homeowner ❑ 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 1 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: Y)11Z4y 4Lit �f sAC__-
• 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 ford • revoc.inr1 of my license aid rosecu. under M.G.L.Ch.268,Section 1.
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Applicant's Signature: . \c:., l
Date: /� `!' ►—p
t
Owners Signature(or attachment) ` Date:
Approved By: i`'"°' Date: � i
Building O ( EMAIL. SS:
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 ❑ No
The Commonwealth of Massachusetts
r .—_, , _ L Department of Industrial Accidents
_"Al= 1 Congress Street, Suite 100
_= �= Boston, MA 02114-2017
www.mass,gov/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): 41 0 V la.-4- �' 6 - i3/f4971 C i
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
l.El 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 8. E Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
10 � Building addition
3. I am a homeowner doing all work myself.[No workers'comp. insurance required.]t
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.❑ 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 13.Q Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
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 he ti under the pai nd penalties of perjury that the information provided above is true and correct.
Signature: ,, , N.),)45:9\`_ Date: 1/ Q
Phone#: c -- 6--
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#: