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Home My WebLink AboutBld-20-002358 _ Office Use Only 1.1 _o �YAR` Permit# 'ram ;ry! t. :0 - ul - . H r:Amount SD— b' -_ °,+.a.....0 Ecd. Permit expires 180 days from '; :_4;i:.: ::.•, .1_ (.b—ap_ issue date REC I :" _ ; EXPRESS BUILDING PERMIT APPLICATI ' TOWN OF YARMOUTH I OCT 2 2Oi Yarmouth Building Department 1146 Route 28 - ' r • ' "WWI South Yarmouth, MA 02664 - (5508) 398-2231Ext. 1261 (,� M CONSTRUCTION ADDRESS: �% VD Pt R ! _'P� c,L.G \--). 0 1 A 1�1 t0 oft{ p Q �"ir , ASSESSOR'S INFORMATION: • • Map: Parcel: OWNER: CA-(UO 1 Q J 1 CS UP:sAaN(1 cLE CZt \Ip,c r'ov vi Poch `1 44-2a1I(lgi NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ CC ()DO Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workmanmpensation Insurance: (check one) 43 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:# Replacement doors: # ,..7Roofin: ##of Squares)_tp j , ( )Remove existing* (max.2 layers) Insulation ri, Le la Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *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: � " /Owners Signature(or attachment) Date: \0— -1 Oo t' ) v Approved By: 1./ Date: /O "— '�7' Bui g O al r designee) EN DRESS: 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 0 No _ The Commonwealth of Massachusetts / l'k---1.5iii-7—€jj Department oflndustrialAccidents 1 Congress Street, Suite 100 rt=� `= Boston, MA 02114-2017 s•`' www.mass' ov/dia Mt Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): Address: D A(z N A LlCs 0 01 ncw l‘'I VO CZ--( ("1 R 1/ City/State/Zip: ej r (o` C-) Phone #: `TTA -'D(g _ \YR 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. 0 Remodeling an capacity.[No workers'comp.insurance required.] Lf✓�/ 9. ❑ Demolition 3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 0 Building addition 4.❑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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 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.❑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 hereb certzfy under the pains and penalties of perjury that the information provided above is true and correct. Signature: \‘k. aMr.Cb?la— Date: \O — .1 y J0 `_ ) !/ Phone#: 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#: