HomeMy WebLinkAboutBld-20-001654 `•,O ,Y— ce Use Only
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„Permit expires 180 days from '
_3 issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department 5
1146 Route 28 1
South Yarmouth, MA 02664 3 :l 25 (TN i '
(508) 398-2231 Ext. 1261
G � "
CONSTRUCTION ADDRESS: 2I SUJMV IP * : A' 9)4A94 T,41 .lot- ._
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER oCJ£(J f RNf 1E 22 Li A - - 213 3� � � C �9 5Lv �v �/�� R� �/7 9.� �
NAMMEE PRESENT ADDRESS TEL. #
CONTRACTOR: &(liat1} T6/ '.7 �'c 213 e-r -. c-1,s-/ 1 6, 7c9
NAME MAILING ADDRESS TEL.#
ji
'Residential 0 Commercial / Est.Cost of Construction$ °��/`�
Home Improvement Contractor Lic.# / c b� / Construction Supervisor Lic.# JUC --4‘
Workman's Compensation Insurance: ,(check one)
0 I am the homeowner 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 y 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 tit"7A %4 2 ./.2/5/19/1`L
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 revocationof my license and for prosecution under M.G.L.Ch.268,Section 1. /
Applicant's Signature: 9 0(33'% /t' AjA 2.c --7 Date: U`7/- / /r�
Owners Signature(or attachment)/ yikein-701..."4; Date: O'gf®,r/L 5/
Approved By: �� - Date: �J�5 —'7
Building Official( esi EMAIL AD SS:
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft of Wetlands:
0 Yes 0 No 0 Yes 0 No
1 he Commonwealth of Massachusetts
r >tF= � � Department of Industrial Accidents
I= 1 Congress Street, Suite 100
= T1 Boston, MA.02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information PIease Print Legibly
Name (Business/Organization/Individual): r`ity�,�>
Address: ' uy?� )� E - i7/1
City/State/Zip: 1%u` t `YJ %Phone '. ,=; �6 `2
Are you an employer?Check the appropriate box:
I Type of project(required):
1.❑I am a employer with employees(full and/or part-time)_*
" %• ❑New construction
2.1am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 9 Ill Remodeling
3.❑I am a homeowner doing all work myself[No workers'comp_insurance required.]t Demolition
4. I am a homeowner and will be '0 (-- Building addition
❑ hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole ( I I.I Elecu ical repairs or additions
proprietors with no employees.
1_.u Plumbing racing 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.= 1=- RAC-:epair5
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I o-==r �����' �� Ji`�L�_9
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box;1i must also till out the section below showing their workers'compensation policy ir:crm_.ic-_
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new__ t do g ,
}Contractors that check this box must attashowing — such_
iC�ed an sd:�enal sheet the name of the sub-contractors and state whether-_c;r:�,s.:e.-ties��e
employees. Lithe sub-con actors have employees,they must provide their workers'comp.policy number.
I am an employer that is providrno workers'comveytsaiion insurance for my employees Below is rhe.poZi.sy and job the
information.
Insurance Company Name:
Policy 4 or Self-ins.Lic.A: Expiration Date:
Job Site Address: 24 Sw/1-2 Lrt(-6 ' City/State/Zip: C.—657
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 S1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 3250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DL k for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is nue and correct.
S iziature: ,-?/
Date: : rc/' 2 5/2c)i y
Phone#: ,ICI 3347E )5`�"
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone-:
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