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Home My WebLink AboutBld-20-00382 ;Y _ Office Use Only IPermit# .telf,1*4 SD- 0 1 . H ; Amount ` MATTACM L3 ^� '= " �d • "Permit expires 180 days from _ ;•- '' '/''\\ /I issue date EXPRESS BUILDING PERMIT APPLICATION_ TOWN OF YARMOUTH Yarmouth Building Department 1 i, L z u 1146 Route 28 South Yarmouth, MA 02664 CO: t.D3(4 (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: pl.Oej (3//fie...RC,(// I'( ASSESSOR'S INFORMATION: Map: Parcel: OWNER: I b rnh14 I )1—k_ /0 C1011 C " WA1rA t iJ7 CO�j Ji NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Zesidential ❑Commercial Est.Cost of Construction c()6 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) IK am 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 �C� 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: \ C.)\✓1"J \-)'V Y'n 1 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 rev ation of my license and f prosecu under M.G.L.Ch.268,Section 1. ^^►► l Applicant's Sib ature: Date: 7'Q` —/ , Owners Signature(or attachment) Date: 7i e' 3_—// Approved By: Date: , / 7 Build. c' or de ' ee) ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ' No The Commonwealth of Massachusetts , Department of Industrial Accidents 1 Congress Street, Suite 100 I T A< Boston, MA 02114-2017 M„��•`''� 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): 740/0)() S Y n'• c cr f v`r' <f Address: i'O j c,i City/State/Zip: Lj417/7c7;7t /114 081,4/s-7 Phone #: //7 - 1-65 = / 7 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. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.Pam a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp. insurance required.]' 10 ❑ 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.❑ 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.❑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. i 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 penalti s of perjury that the information provided above is true and correct. Date: a - i �' t� ne#: /7 " GCS: '/ 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#: \_/ 16 it M-t 41 ,it-ce' L llIc-vtcs 1 flan. i1A-1e a,O L /3/vc 1)t 1 kl Pitt per '1wve rr-r re sis6 rk- t ckF-\tS rvC7 opt./ ,S C.t ✓►h • a- J V