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Home My WebLink AboutBld-20-000483 -yqR Office Use Only "a O Pe " l . H 'Amount G 1UTTA M CSE �`"'•°••�c0»'E d 3 Permit expires 180 days from {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 •, G �3 (508) 398-2231 Ext. 1261 [ to CONSTRUCTION ADDRESS: ;-‘:1' CES S E-`3 bE-t- , S. /A r2 MO L.ITH M A 0 266 4 ASSESSOR'S INFORMATION: Map: Parcel: OWNER:DtANA A: LAr`ir Z -26 3 I& -o537 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# 'Residential 0 Commercial Est.Cost of Construction$ Z. Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) %' I am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED � � e /,v -tee ei 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:K 7' 7v$!-e—P2 57frif70i\J 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. (�-lic•� ! Date: 2.q I 20<9 Owners Signature(or attachment) „ Date: ;147 90,7 Approved By: Date: 7- Buildin" (or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ 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 j 1 Congress Street, Suite 100 Boston, MA 02114-2017 `�M�5.•`''� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): - 1AJ A A Address: 2c-, r s s s ,— City/State/Zip: 3 /A RNt -t c -r JG1t1- a24 phone #: .7(,"0 -333 - 2(S 2 l SGTC-39 —OS3 7 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. E Remodeling any capacity.[No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]` 10 ❑ Building addition 4.ny I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole i 1.❑ 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.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.i 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other C'H/M/✓f y 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-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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: G�u�< Date: %Z9 292o/q Phone#: Svc ' 39$ - 0S-3 7�0-3-33 2652 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 4: