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Home My WebLink AboutBld-20-002820 —O :YAR Office Use Only RECEIVED 4o61" Y O �] p� • ;Amount %_�LtnA � $' �V a. 2019 ""•'�° cam.• Permit expires 180 days from issue date BUi1 D1NGDEPARTMENT EXPRESS BUI 1 ING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 G / //��V (508) 398-2231 Ext.er 1261 /� CONSTRUCTION ADDRESS: CA-PTA-IA) key a-� Qc ASSESSOR'S INFORMATION: Map: Parcel:OWNER: OP —K , �dtdti c(W rkii Aii2yR.s Qt cveze 77"/-V87-O7/Df N ME PRE ENT ADDRESS A TEL. # CONTRACTOR: 5 L-Fits Pell�Ci:G'�v U l /( yi *v. 4 , tE MAILING ADDRESS TEL.# Atesidential ❑Commercial Est.Cost of Construction$ 7 a OL Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 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 Replacem t windows:# Replacement doors: # Roofing: #of Squares /6 ( emove existing* (max.2 layers) Insulation 9—Old Kings Highway/Historic Dist. (Replacing like for like Pool fencing *The debris will be disposed of at: )"A U'(/1* 7P-A7V5P 5 J ,ne, 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 denia r revo ation o icense an for prosecution under M.G.L.Ch.268,Section I. '/ Applicant's Signature: �..e, Date: Vo Ij - /y_ / 9 ^ Owners Signature(or a 'c ment) CCI`T , Date: Approved By: Date: l y// 1 uilding Official(or designee) EMAIL ADDRESS: Zoning District: _ Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No • The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 um,"' -5�• www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organizatio Individual)) 'SO t+N QP D Lig-K Address: 6'0 C -fk o f3,S y City/State/Zip: // Wj co T 44 - Phone 4: 7 7 /- 'i 7- 0 7/6/ Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.E 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. I am a homeowner doing all work myself.[No workers'comp. insurance required.] 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYProPrtY e I will 10 Building addition 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.E1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.r ir oaf repairs These sub-contractors have employees and have workers'comp. insurance.i 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. I.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 4 or Self-ins. Lic. fr: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' co sation policy declaration page(showing the policy number and expiration date). Failure to secure cover s required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-ye ' risonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day aga' 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 ains and penalties of perjury that the information provided above is true and correct. Signature: ! ( f� 0-7 / Date: A) '(f / /. � Phone#: 7 7 g— y 7— /6 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 TM: