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Home My WebLink Aboutbld-20-002199 Office Use Only P , •V :i Y`gR,i� 1 • Permit# ,, r ! II v 1-If =Amount ''.(`/� 11ATTAlA [S .m..aoo ELd, ^Permit expires 180 days from - :.::.. ( 1�q D'-�(6q et. A issue date ^- EXPRESS BUILDING PERMIT APPLICATION„,,._ --. -- TOWN OF YARMOUTH 1 Yarmouth Building Department 1146 Route 28 _.,.._,,_ —..- South Yarmouth, MA 02664 Bu1L-L.' �t�H�z�"cNT (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I✓14C b21 ' 1 1►►4) 6-zo ASSESSOR'S INFORMATION: 'f_ Map:Ma Parcel: �j OWNER: / V✓1 r/ 't Z� ,) s. WICI C-cbilsi/T . D �t1 — ?SS� N ] j� PRESENT DDRESS TEL. # 1 /� j CONTRACTOR: W C ��C 64 l '3cthr Pc 5-4- 'PA i6{ - �gG '/• ii L7 7 NAME MAILING ADDRESS L j TEL # ) Crt) go sidential 0 Commercial Est.Cost of Construction$ .C) . Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman/'�Compensation Insurance: (check one) CYi am the homeowner 0 I am the sole proprietor Worker's Compensation Insurance Insurance Company Name/ c..._0, Worker's Comp.Policy#) ,\ WORK TO BE PERFORMED 1'\ 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: S' J E[p, Lod fit"s j k soubl ocivvc 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 revocatio o . ense and for pr tion under M.G.L.Ch.268,Section 1. Applicant's Signature: (VA Date: d/ f y / Owners Signature(or attachment) Date: f ii I VI Approved By: ,,,� 1/ Date: Building Official(or esignee) 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 ❑ No • The Commonwealth of Massachusetts _;�. Department of Industrial Accidents :e1= 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeeibIY Name (Business/Organizatio .dividual WJ "R06.,1f. Address: 23 0„ydec 14n c City/State/Zip: 'e i iJk Phone#: ( - V Are you an employer? ck the appropriate box: Type of project(required): 1.0 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 any capacity.[No workers'comp.insurance required.] 8• ❑yRemodelin' 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]: 9 7/Demolition Demolition No 4. r am a homeowner and will be hiring contractors to conduct allwork on 10 El Building addition ensure that all contractors either have workers'compensation Ce my property. I will proprietors with no employees. or are sole I I.❑Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurances 13.❑Roof repairs S.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] [{*Any applicant that rhorks box#1 must also fill out the section below showing their workers'compensation li information. Homeowners who submit this affidavit indicatingp° °y 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'came 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: t✓e✓)t ) . Policy#or Self-ins.Lic.#: /A-LUC- 334201, _ Expiration Date: / Job Site Address: ;93 y(__ Cc,.,e C' /State/Zi Attach a copy of the workers' compensation policy declaration page(showing the policy rhmber d 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: (5 �c,��_ Date: 7 Phone#: -gyp.- )f_ GPyt Official use only. Do not write in this area,to be completed by city or town offtejii! City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. BuildingDepartment 3.Ci wpPlumbing /Ton Clerk 4. Electrical Inspector 5. Inspector 6. Other p ` Contact Person: Phone#: