Loading...
HomeMy WebLinkAboutBld-20-001663 •Oi,YA w office e } Only -0/ /� OF �41 ,, Amount ` MATT M I t�.wc. E Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146Route28 SEE' 26 201,j South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 '" `'' f CONSTRUCTION ADDRESS: 21 lcE'.M �b ASSESSOR'S INFORMATION: Map: Parcel: ,y OWNER: FA( C ffit-6 L TO f- < 2/ !CP-N Q> 974 268 l o f I NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# residential 0 Commercial Est.Cost of Construction$ 30- v - ?) Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm Compensation Insurance: (check one) lam 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 2 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: 60C loge ge S / `Q 6 , 5- 'A-1"-W vl tt 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 revo n ofer .G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature r attachment) Date: Approved By: 1 1/ Date: 5 's v -'77 Building ci d ' ee) EMAIL DRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 17 Yes L I No Yes No , . The Commonwealth of Massachusetts 1 _Al l_ +t Department of Industrial Accidents =�jj=ll l= 1 Congress Street, Suite 100 `: ilf Boston, MA 02114-2017 '"" t' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE RILED WITH THE PERMITTING AUTHORITY. Applicant Information �,� �® Please Print Legibly ,1 Name (Business/Organization/individual): ►'` / C I/4-6 L !(� �� Address: a( i:'of( I2 City/State/Zip: $- y-a C(g t(4- o26,6 Phone#: 9 — 26`8 — /e9 9)C'Are you an employer?Check the appropriate box: Type of project(required): I.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3. I amrlY' a homeowner doing all work myself[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiringcontractors to conduct all work on10 Building addition 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.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.: _ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 7�1�1��AC1;1�1 t l 152,§1(4),and we have no employees.[No workers'comp.insurance required.] W7 N.15DW 5 *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 u the th the information provided above is true and correct. Signature: Date: . o2a• /7 Phone#: 7 7-21 - -26 8 - l© 77 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#: