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EXPRESS BUILDING PERMIT APPLICATIdJT! S E I V E D
TOWN OF YARMOUTH
Yarmouth Building Department AUG 05 2019
1146 Route 28 ___ __ _ _ _
South Yarmouth, MA 02664 13UIL TMENT
AY __ —
((508) 398-2231 Ext. 1261 __
Se—CONSTRUCTION ADDRESS: ( A b e//5 i i:A Q6 ( I/
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: pef.,1c fa(...0)fr 57 /4b-ells zCo( 77(7..11,). 1d
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.'#) /
Residential ❑Commercial Est.Cost of Construction$ ! ()0(1) V
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Worlcman's Compensation Insurance: (check one)
X I am 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 0 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:
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 ation of my licens.= and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Ada.; ._.1 ,/v Date:W.
Owners Signatu-• (or a ment)
� Date:
Approved B .` _ —t/ /. Date: d & .
Building•'ial(or resit'-e) EMAIL ADDRESS:
Zoning District
Historical District: ❑ Yes 0 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
sit 1 Congress Street, Suite 100
Silk= Boston, MA 02114-2017
M;,5.• 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): De(eK_ /
Address: Si A b-C//3 &,),(
City/State/Zip: l/O arynG U f Phone #: 7 T V l a- / 0 _
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity. [No workers'comp.insurance required.]
9. ❑ Demolition
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
10 ❑ Building addition
4.D 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 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 1-, E Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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.
1-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 p nder the pai and penalties of perjury that the information provided above is true and correct.
Signature: % L ,belk Date: 3-` J
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#: