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Home My WebLink Aboutbld-20-002210 Permit# N. •O ,,, I11.' H; 'Amount /OD -D (11 ��• MATT M ,COSCJ�'1 "'"" ;' 1 Permit expires 180 days from j issue date EXPRESS BUILDING PERMIT APPLICATIOIR E C E I V E C. TOWN OF YARMOUTH I 1 Yarmouth Building Department OCT 21 2019 1 , 1146 Route 28 South Yarmouth, MA 02664 SUIT T"�T (508) 398-2231 Ext. 1261 By CONSTRUCTION ADDRESS: 7 m jf St \I qir mou r t 1 'AA ck ASSESSOR'S INFORMATION: Map: Parcel:C, OWNER: CQ— Y c tZ (\J P V 1 MSM J 1 h 4_ i —7 Li3 In &' S 7 7 L4 NAME I PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# X Residential ❑Commercial Est.Cost of Construction$ ,j O D b. oD Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) lit I am the homeowner ❑ 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: #_i_ Replacement doors: # Roofing: #of Squares ( )Remove existing* (max. 2 layers) Insulation 1Oi8il t9 ld Kings Highway/Historic Dist. (Replacing like for like s - -- Pool fencing viM1L ?5c-.A.0, *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: f �p2`/�9 Owners Signature(or attachment) Date: Approved By: (� --(,y° Date: 0 -4.1 -1CI Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 419 Boston, MA 02114-2017 5�• www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): � k Address: 1 TA S van 1 n e S City/State/Zip: \(j y Pa., t Phone #: —? ? Li-3 Are you an employer?Check the appropriate box: Type of project(required): l.❑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 8. ItRemodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ _ y [No workers'comp. insurance required.]t 4.C I am a homeowner and will be hiring contractors to conduct all work on mYP 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. 12.0 Plumbing repairs or additions 6.C 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_C 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 checks box R1 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 pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /U Phone 71 Li- 3 c, 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. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: