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EXPRESS BUILDING PERMIT APPLICATI 1cfe E I V E D
TOWN OF YARMOUTH ._------- ... ..--i
Yarmouth Building Department
1146Route28
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South Yarmouth, MA 02664 ! P nn i_N r
(508) 398-2231 Ext. 1261 5 :3,,
CONSTRUCTION ADDRESS: ,F/')/1) / / /4 i/F
ASSESSOR'S INFORMATION:
Map: Parcel:
c-- 2)J ��r_� L S Sc ntit _cog` 369 g 2/S`"
OWNER: A /,9L
NAME
-- PRESENT—ADDRESS TEL. #
CONTRACTOR: ._✓ �J/
NAME MAILING ADDRESS TEL.#
❑Residential 0 Commercial Est.Cost of Construction$ G, 29e)V
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Wor(Crnap. Compensation Insurance: (check one)
id I am the homeowner 0 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 �� 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:
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 of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date:
• Owners Signa e(or attac.meat) .6._ Date: /c//AgT \/9
Approved By: s i Date: )' • 2 f '/ /
Building 0 c' e) EMAIL 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 0 No
The Commonwealth of Massachusetts
_ _ I Department oflndustrialAccidents
le 1 Congress Street, Suite 100
4 _a `_ Boston, MA 02114-2017
4.7
www.mass.gov/dia
NM
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): /�/�, 4 / P/e;Z i./`r /C
Address: Cfj ?E-A),A) C"7-7" i•)-1./-
City/State/Zip: Ola/Z///o 1---A.._ Phone #: ...5-0? a F.,S
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
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
3.'i -am a homeowner doing all work myself.[No workers'comp. insurance required.]t
10 E Building addition
4.0 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.Q Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 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 u r he pa' nd penalties of perjury that the information provided above is true and correct.
• Signature/ Date: ,C4/ // ,:f7/7
Phone*: ..‹-ng v Cif V
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#: