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Permit#
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH 7_ _.E. t ,'9� E o
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Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664 ' `j 1n11
(508) 398-2231 Ext. 1261 :,�, ,� 1;r -_;
CONSTRUCTION ADDRESS: 8& /(y l LLr S AR...
ASSESSOR'S INFORMATION:
Map: 78 Parcel: m - /,,
OWNER: 2 j6/�• 3 ,1�'SC 8 / at;./S 2 & 5t7&. 7 G (a - OW- 7
NAME PRESENT ADDfRESS TEL. #
CONTRACTOR: R.oAi 3 cf2 L/A) 64/14' ( g Sr 4-)34. / ) . Ste$--7%-acW
NAME MAILING ADDRESS TEL.#
XResidential 0 Commercial Est.Cost of Construction$ WO.
Home Improvement Contractor Lic.# /31 Y 76 Construction Supervisor Lic.# a 99495-
Workman's Compensation Insuranceeck one)
0 I am the homeowner si 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 9s6
. Replacement windows:# 6. Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. (X)Replacing like for like Pool fencing
*The debris will be disposed of at: S4 3 5�.0 .ko /S
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 o °-voc• f my li nse and fosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: ♦? ' t Date: 1 Q
/3/ 19
Owners Signature(or attachment) & , t- Date: �13/i f
Approved By: `, Date: 7 3 /?
Building Official(or/ i EMAIL ADD S:
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
=W, = Department of Industrial Accidents
tE_Lin1't= 1 Congress Street, Suite 100
_tit= Boston, MA 02114-2017
imp 5.* 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): fpj,J 3 €. P% —r$3 Gn MV-
Address: P. Oi', � ?-
City/State/Zip: lam, C3.f)j 7,i& q Phone #: - 7?c — w/'
Are you an employer?Check the appropriate box: ,
Type of project(required):
1.❑IIaam a employer with employees(full and/or part-time).* 7. El New construction
2.0 am a sole proprietor or partnership and have no employees working for me in 8. 'modeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all work myself. 9. ❑ Demolition
❑ y [No workers'comp. insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work on mYProPrtY•
e 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.❑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.= II� q
6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other �!/N A lf,�
152,§1(4),and we have no employees. [No workers'comp. insurance required.] j!A IA)
*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 pai and penalties of perjury that the information provided above is true and correct.
Signature: `5 ---I r Date: /"'v ' Il
Phone#: __T- - 77 6.-,ciy-
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#: