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1 RECEIVELJ
EXPRESS BUILDING PERMIT APPLICATIO 4
TOWN OF YARMOUTH OCT 1- 2019
Yarmouth Building Department .._.
1146 Route 28 avi� E n N�.
3y.
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
/4' Fi �eet) uCONSTRUCTION ADDRESS: �� /ift�!7 "
y
ASSESSOR'S INFORMATION:
Map: c/� Parcel: C
OWNER: -t Qf7L2,0JfC// �/'C' �iii[ ! o g OJ .$ /
NAME PRES ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TE #
Residential 0 Commercial Est.Cost of Construction$
Home Improvement Contractor Lic.# Construction Supervisor Lic.
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 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 Replacement windows:# Replacement doors: #
Roofing: #of Squares /5 9 ( )Remove existing* (max.2 layers) Insulation
v 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 Signature(or attachment) Date:
Approved By: Date: / 072-I ' 1
Building Offic or d ee 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 ❑ Yes ❑ No
The Commonwealth of Massachusetts
Department oflndustrialAccidents
�el= 1 Congress Street, Suite 100
_ 4- , Boston, MA 02114-2017
IN,,;�5.•`''�Workers'
www.mass.gov/dia
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
1
Name (Business/Organization/Individual): "� mo*/ le/Gel
Address: V14/1041 _c 74 7197P — oiq f ___
City/State/Zip: a2ej 4-5— Phone #: 410 0 6 fl C Fs'(6 cf
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.]
3.L(v I/am a homeowner doing all work myself. [No workers'comp.insurance required.] 9. ❑ Demolition
4.❑ my
I am a homeowner and will be hiring contractors to conduct all work on property. I will I O ❑ 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.
These sub-contractors have employees and have workers'comp.insurance. 13.❑Roof repairs
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.
r 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 d r the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: L .
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 i#: