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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 c
CONSTRUCTION ADDRESS: agc- Q/19 2/1/a i y-, S:Ar'est*--
ASSESSOR'S INFORMATION:
Map: f Parcel: C Q��}
OWNER: /�N l�e/ Ccce\ ,5 ®yd �I YI 5+ JO VY6-i��' V
lA
PRESET\ R SS TEL. #
CONTRACTOR: L(r /► / ChafilatA �I�� YO2 62*
NAME `V MAILING ADDRESS L.#
"Residential 0 Commercial Est.Cost of Construction$ ✓
Home Improvement Contractor Lic.# // 6i 3 . Construction Supervisor Lic.# C 5 ""O AQ/)
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance , , - .3 -,
Insurance Company Name: Worker's Comp.Policy-
WORK TO BE PERFORMED , � 2,h 1J1`�
Tent Duration (Fire Retardant Certificate attached?) ' Wgad Stove
Siding: #of Squares C Replacement windows:# Replacement doors: #
Roofing: #of Squares i6� ( / )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at Gl I .0 V+ ► l W
Location of Facility
I declare under penalties of perj that the statements rein contained are tru d c rrect to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or ocation y 1. e and for prosecutio e {rL.Ch.268,Section 1.
Applicant's Signature: Date: 0/1
Owners Signature(or atta .ent) L- Date: 2 J <
Approved By: ' ' Date: r - o- //
r/ilding Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
The Commonwealth of Massachusetts
r r, Department oflndustrialAccidents
1 Congress Street, Suite 100
k Boston, MA 02114-2017
_....5�•`'r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Pleas Print Legibly
Name (Business/Organization/Individual): (�
Address: il'et „AO
City/State/Zip:eU _Ya�1/'mei v 1-00/7 ' QP'f % 2 ,,,
Are you an employer?Check the appropriate box: Type of project(required):
1.III -- a employer with employees(full and/or part-time).* 7. _New construction
2.`,%�, a sole proprietor or partnership and have no employees working for me in 8. E Remodeling
any capacity. [No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t
9. _ Demolition
10 El Building addition
4.E I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure t all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
pro ' ors 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.Q 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 hereby cer uncle//ze pa s and .•nalties of.lury that the information provided above is true and correct.
nature: if t .. . /,�ll./ Date: jfa/al-- or9v5 0.61/
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#:
9/25/2019 123_1.jpeg
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Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration Expiration
196632 09/07/2021
SCOTT SZYMAKOWSKI
SCOTT A.SZYMAKOW SKI
7 MAYFLOWER LANE
SOUTH YARMOUTH,MA 02664 Undersecretary
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