Loading...
HomeMy WebLinkAboutBld-20-002374 .r:. ;Y� Office Use Only O `�•y'E H Amount (�� t '�� MATTAIPf CS[E. ' - __%3 knew Row9,V., Permit expires 180 days from *,; :- issue date EXPRESS BUILDING PERMIT APPLICATION E CEIVED 1\ TOWN OF YARMOUTH Yarmouth Building Department i fit.) cliQ 1146 Route 28 .__.,. South Yarmouth, MA 02664 r; -,)',PARTMENi (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: k 2 7 itivj ite, id i-1 i OJ(,/ICI ASSESSOR'S INFORMATION: y[ Map: Parcel: OWNER: '\ ✓pia" D9,762, h.p 7 to vi/ EQ Mil 77tf 't/7- cfr/69 NAME PRESENT ADDRESS TEL. # CONTRACTOR: 1/42 Ey t?, 5ataxi— NAME MAILING ADDRESS TEL.# ,Residential 0 Commercial Est.Cost of Construction$< It Z 300 Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workm 's Compensation Insurance: (check one) IQ 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 n/ Siding: #of Squares 7 ?S 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: Mr n b t'r i 1 ` Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my lmowledge 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: ' wners Signature(or attachment) c.7,Qei4.7 p Date: © / Approved By: , �'/ Date: 0 2cu '- Buil7.'I...' (or designee) IAIL 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 0 Yes 0 No _ The Commonwealth of Massachusetts r Department of Industrial Accidents _fr/'1_= 1 Congress Street, Suite 100 In _�:�= Boston, MA 02114-2017 4v ,,,;;5e• 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): )(AX. ddress: ie 7 1- /w/( Rd City/State/Zip: 6. r,�,� y D2�o�nct Phone #: 77(t_ et/7 - cii 6} Are you an employer?Check the appropriate box: Type of project(required): 1.0 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. E Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 10 Building addition 4.❑ 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.❑ 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 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 afridavit 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. AQnature: c/eq,? Do r cc_ Date: /0/Z0'3 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#: