HomeMy WebLinkAboutBld-20-001154 z
,q� Office Use Only
. 01.Y �Permit# $
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Q - l,!r, H Amount 50
.`� MATT M [SE 4.:
Permit expires 180 days from
: issue date
EXPRESS BUILDING PERMIT APPLICATION r �__
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TOWN OF YARMOUTH 1 1 AUG Z�19
Yarmouth Building Department i "fir y„ _.,_ .,�-
1146 Route 28
E>L1 --7)D—t(si South Yarmouth,MA 02664 <
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: &O COO I Rd �/I i -1 a ffy)ou--1 0„9613 N'
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: Lkalucto axYW '8.0 ea)liGN, ed WApatUChl atib+1 - 194 026 13-5
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
19'Residential 0 Commercial Est.Cost of Construction$) 3 000c DO
Home Improvement Contractor Lie.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
124%I am the homeowner 0 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 ff'' Replacement windows:# Replacement doors: #
Roofing: #of Squares (2`t ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: (71 °van( Br �1,.
Location of F�ty
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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
A Cpplicant's Signature: 14—a- ��� Date: :l/30 I ( 1
Owners Signature(or h ent) Date:
Approved By: '" Date: �3 j�
lding Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ 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 oflndustrialAccidents
_LA- 1 Congress Street, Suite 100
-' = 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 Please Print Legibly
me (Business/Organization/Individual): cutC/) aenc).)
Address: ' U QOO1 i dry, W Q{rn Ou) 'h
City/State/Zip: Mee 7?j �1 Phone #: I - c26 - 11-5 A
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. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3. 4 am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑ Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. 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.❑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.$ 13. Roof repairs
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.
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 under the pains and penalties of perjury that the information provided above is true and correct.
Siarlae: Date: j3OJI9
Phone#: I1�1' c? 151
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 CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#: