HomeMy WebLinkAboutBld-20-00392 .��,YRR Office Use Only
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issue date
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EXPRESS BUILDING PERMIT APPLICATI
TOWN OF YARMOUTH 7JUL 2 3 2019
Yarmouth Building Department
1146 Route 28 `j uy _ aN, 1
South Yarmouth, MA 02664
(508) 398-2231/ Ext. 1261 ,/
CONSTRUCTION ADDRESS: CRS F •
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ASSESSOR'S INFORMATION:
Map: n Parcel:
OWNER: Te.,--1-cri—��6 Q(S 6 r1-e,51- /Z G� S-O Op q!�-`S // r
NAME PRESEN AADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
1$esidential ❑Commercial Est.Cost of Construction$ a ` 000
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
A I am the homeowner ❑ I 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 / 0 • ✓ Replacement windows:#___F Replacement doors: # f
Roofing: #of Squares t i ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at i a1/140 1J 411 —1—(--a AfS Fen_ .S j i 'ate(
Location of Facility
I declare under penalties of "ury that the ate ,• is 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 deni or revoca" of m " ense and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: /
�` Date: {
Owners Signature(or attachment) Date: `
Z
Approved By: ) ' 1"3 I S •
Building Date:
e Official(or designee) EMAIL ADDRESS:
Zoning District:
r.'o Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
`1' Water Resource Protection District: Within 100 ft.of Wetlands:
r� �1, 0 Yes 0 No 0 Yes 0 No
The Commonwealth of Massachusetts
Department oflndustrialAccidents
fiet 1 Congress Street, Suite 100
_� ►c Boston, MA 02114-2017
s.• www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
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.]
9. ❑ Demolition
3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
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
6.❑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.
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 penalties of perjury that the information provided above is true and correct.
Signature: Date:
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#: