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Home My WebLink AboutBld-20-002955 - dog.. 4,R k s�,. ' `tC � i4nit w ' 4C1 O . , I�' . y 'Amount S �MATTA M L_S( �,U,\..,00aCe%�d� (Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 s CONSTRUCTION ADDRESS: i t-- BLitt C r c p Lan ScJ+11. yCLoviouthMA 0 2 (,4--I(O0 ASSESSOR'S INFORMATION: Map: /19 Parcel: I.L3 4,_ 3 OWNER: )) d-C 6 etie►e L crncs 1413 rcc.# £44 Sco�`F� and -1._irh /hA Sb '-394-—4o 4 I NAME PRESENT ADDRESS / TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# /� n Q H Residential ❑Commercial Est.Cost of Construction$ / 8 8, Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) BSI am the homeowner : I am the sole proprietor ❑ I have Worker's Compensation Insuratce Insurance Company Name: Worker's Comp.Policy# 3 i,4 sV 0'.� WORK TO BE PERFORMED 6(io ,w Tent ' Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # / Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Y Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 04 CM...0.J j L- vt•hol. 1:10411,f 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 tion of my license and for prosecution under M.G.L.Ch.268,Section 1. applicant's Signature: .-2`� Date: // ' 0 e..9? Owners Signature(or attachment) . Date: / ! —.2?) — / 7 2-- ----- :.,Approved By: 4 Date: // --E/P Building Offi (o signe E ADDRESS: S��!-'i-IC,y c_r► 0 1i a+m&L! • cEYn • Zoning District: Historical District: ❑ Yes 11 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No ❑ Yes , No The Commonwealth of Massachusetts r ir Department of Industrial Accidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 5.• www.mass.gov/dia r. \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ?q.✓ / L./ n CS Address: /1- City/State/Zip: So✓+6l / t-4 Mit Phone #: 3"L _46 2-- Are you an employer?Check the appropriate box: Type of project(required): 1.E 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. ❑ 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. ❑ emolition I0 [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.❑ 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. 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. r 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 under the pains and penalties of perjury that the information provided above is true and correct. ignature: 9 , �/ Date: //—,a.D 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#: