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Home My WebLink AboutBld-20-000384 _.x i' 1 q1.•Y4.4tt ce Use Only • Ou. 11 . 0-3 _{Amount /� ri G MATTACl1 ESE�� 4`°'°°""`°'gyp E 3 Permit expires 180 days from ,{issue date 915if im6 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 q Of 114< 0i r)f`i L (' S / t u`14 v 1i(sN r P ASSESSOR'S INFORMATION: Map: q n/1 Parcel: C� / (, OWNER: �CO pr/ 'V 3 VD14 zY-1C liA."( sQC) SW7 d 4 2,(v NAME PRESENT ADMESS TEL. # CONTRACTOR: cc0 if r4v- S t 5 5 F4 E NA L NAME MAILING ADDRESS TEL.# esidentiat ❑Commercial Est.Cost of Construction$ 2,0O0+ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's ensation Insurance: (check one) am the homeowner ❑ I am the sole proprietor u 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 3 Replacement windows:# 3 Replacement doors: # -- Roofing: #of Squares q ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Ti r MD c. rt1 D(J tvt t), Location of Facijiity I declare under penalties of perj ry t at the statements herei ontained 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 vo ti of my li ns an for prosecution under M.G.L.Ch.268,Section 1. 7/2Applicant's Signature: �`` U-L' Date: / Owners Signature(or attachment) Date: Approved By: Date: > .. 5`_r- Build. ici designee) EMAIL SS: Zoning District: Historical District: ❑ Yes 11 No Flood Plain Zone: C Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes 0 No ❑ Yes 0 No • The Commonwealth of Massachusetts -r } L Department oflndustrialAccidents , � 1 Congress Street, Suite 100 r `" Boston, MA 02114-2017 NIP5y•''` www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Na S NamerR, �no��in _ir � a,.,��' �O J .i/tc Address: 3 City/State/Zip: i+>es rr ^ Phone #: SO 8 7 d 1-4, Are you an employer?Check the appropriate box: Type of project(required): I. 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 g 8. Remodeling any capacity.[No workers'comp.insurance required.] _ 3. am a homeowner doing all work myself. [No workers'comp. insurance required.] 9. _ Demolition 4.C I am a homeowner and will be hiring contractors to conduct all work on mYproperty. 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.Q Plumbing repairs or additions 5.E 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. 4: 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 under the p 'ns d penalties of perjury that the information provided a ove is tr e and correct. Signature: . 23 r CI Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 74 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: