The URL can be used to link to this page

Home My WebLink AboutBld-19-006775 r,r'- ;YA Office Use Only .i- O R 1!'Z" �!.et�; 1 Permit# •O . it .„Hi Amount \'e4 MATTACM s,E�„' , -.40,04..10*- O I issue date Permit expires 180 days from '//�/)�///� I3L11w`)_1q —COO ,, 4i •f ri d ... EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH MAY '3 i' c[)i Yarmouth Building Department 1146 Route 28 F Ciii S South Yarmouth, MA 02 664 C� (508) 398-2231eExt. 1261 I • ' CONSTRUCTION ADDRESS: 2 ` U�r (; ✓l,k L1 `�J E�a c+'lJ✓IllWl., *413 ASSESSOR'S INFORMATION: Map: � L' Parcel: OWNER: Ds:WV-, Vek(it2c` t ; •'I�Y�l ‘lf,,,s''t"v-✓it CA..G-v 167►'/13-36y...2 s-s7 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# DiResidential 0 Commercial Est.Cost of Construction$ 6/w..( CD 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:# 2 Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing t °-.1 *The debris will be disposed of at: C!/� M d�l Location of Facility I declare under penalties of pe i ry 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\vocation (--, license and for prosecution under M.G.L.Ch.268,Section 1. h/ G/ Applicant's Signature: ,fir Date: . 3(// Owners Signature(or attachment Date: 3-73/A Approved By: li,� '� 3� q PP 1 -� Date: ) Building Official(or desi. ee) ' ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No ;' . The Commonwealth of Massachusetts ''p." Department oflndustrialAccidents 1j I 1 Congress Street, Suite 100 Boston, MA 02114-2017 •--, „5••`'y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information j� I Please Print Legibly Name (Business/Organization/Individual): b 4iA �-�t�y Address: 2-`t L) ,J, A-i 2, lk.! v ZA4.- 0.1-4 5. City/State/Zipt{ILI i1A-v,tL,UAL sL& �- -13 Phone #: Li[) 361/ — 37 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 :I am a sole proprietor or partnership and have no employees working for me in 8. emodeling ny capacity.[No workers'comp.insurance required.] 3. I flaam a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑ Demolition 4.0 I am my a homeowner and will be hiring contractors to conduct all work on property. I will I 0 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurance.i 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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. 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-contactors 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: 3iD Date: 0/V3 � Phone#: le --36?—2 (c-.7 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#: