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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
I
CONSTRUCTION ADDRESS: c'
ASSESSOR'S INFORMATION: dCG 1
Map: I� Parrcc`el:[��Q,, Q�
OWNER:Dirdot,q4n ����_ Ok Co9 ICE ^v1NAME PRESENT ADDRESS TEL. #
5075 j63Bc-(iz -
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
\Residential 0 Commercial Est.Cost of Construction$ W ,CO
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
> 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 1/ Replacement windows:# Replacement doors: #
Roofing: #of Squares / 4- (Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. (Replacing like for like Pool fencing
*The debris will be disposed of at: n /\ III)_
Location of cil►ty (1:11)
I declare under penalties of perjury that the statements herein contained are true correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or revocati f my . nse and for prosecution er G.L.Ch.268,Section 1.
Applicant's Signature: Date:
Owners Signature(or attachment)CDyc.4..-\, Is,.-.X.X Date: Z" 111
Approved By: -- ,A
PP ' --G.. a Date: I - S -i y
Building Official(or designee EMAIL ADDRESS:
Zoning District: -
Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No �� w �'itt? 1 '
Water Resource Protection District: Within 100 ft.of Wetlands: /V
0 Yes 0 No 0 Yes 0 No ? C',. 5 �]!`-'
The Commonwealth of Massachusetts
;li�► Department of Industrial Accidents
i= 1 Congress Street, Suite 100
=df:F• Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibh
Name (Business/Organization/Individual):eDCj,,J ) C I<I"OW° `
Address: SI- G-evtivk v'd
City/State/Zips 4Zp - k v O 4-1 Phone #: 4S-0/ [f, s" t?
Are you an employer?Check the appropriate box:
Type of project(required):
LE I am a employer with employees(full and/or part-time).* 7. E New construction
2.E 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.�am a homeowner doing all work myself. 9. ❑ Demolition
y [No workers'comp. insurance required.]'
4.❑I am a homeowner and will be hiring contractors to conduct all work on mY P roPertY• I will 10 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
5.0 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
6.0 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.
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 penaltie of perjury that the information provided above is true and correct.
Signature: `"` C
C Date: � Z.'-4 411
Phone#: � (o Q Dij &Z '14
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#: