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Home My WebLink AboutBld-20-1152 Ipentio ,•+ ar_ P. ont;yi; [. O,y 'l' yI[n.'�: <7,ka_c_e^ Lunt5D• — _ ,n Permit expires 180 days from `. "' issue date (3uj'-- 20--( lam EXPRESS BUILDING PERMIT APPLICA ' I 1-;n F ;; E M TOWN OF YAROUTH ` '° Yarmouth Building Department 1146 Route 28 �{C `�1Jd1� South Yarmouth, MA 02664 it r - r2T t _*-1 1 08) 3 8-2231 Ext. 1261 6 _. CONSTRUCTION ADDRESS: // � ,di `� ASSESSOR'S INFORMATION: Map: // 9 Parcel: ( OWNER'S e CC 6 &- o..ecr G,Ve �� 7 .1-5-}C( NAME PRESENT ADDRESS /� / • TEL. # CONTRACTOR: V (c 0�✓ NAME MAILING ADDRESSIgre„, . c'4T �# esidential ❑Commercial Est.Cost of Construction$ - Home Improvement Contractor Lic.# eEirarConstruction Supervisor Lic.# �� -t 8 I ',/ -"?- Workman's Compensation Insurance: (check one) Ill I am the homeowner m 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 77- Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. iklteplacing like for like Pool fencing *The debris will be disposed of at: - - 1 ?(CU )t :' ,//./ 3--' )--2 . 5 c. Location of Facility 1 declare under penalties of per' atements herein containeiare true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denia of m• ' < or prosecution un ? M.G.L.Ch.268,Section I. Applicant's Signatur Date: c9''i/ 11- Owners Signature attachm Date: (�i Approved By: _ ___ Date: i A // Building ucial(or designee) EMAI1.ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 „ram .• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / Please Print Legibly Name (Business/Organizationflndividual): S �/l✓ _ Address: (,- City/State/Zip: Phone #: C-Tirrj3eitAPPf Are you an employer?Check the appropriate box: Type of project(required): 1.1:I am a employer with employees(full and/or part-time).* 7. New construction 2 a nd have no employees working for me in g. rdi glik- •,_ g lT any capacity.[No workers'comp.insurance required.] 3.E I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. U Demolition 10 ! 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.Q Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.[D 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.t 6.]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. 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 oft • workers' compensation poli • I eclaration page(showing the policy number and expiration date). Failure to secu coverage as required under L c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-,-ar imprisonment, as civil penalties in the form of a STOP WORK.ORDER and a fine of up to$250.00 a day aga' st the violator. is statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veric� I do dew"- '.,. perjury that the information provided abov i true and correc Srgna lire: Date: e � Phone#: crreil 97.--"St" 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#: To the Yarmouth Building commissioner, I Scott Coppinger of 128 Driftwood Lane, South Yarmouth, Mass. Do here by grant Scott Collum CS#088218 to act as my agent in the purpose to apply for a building permit to sidewall my house. / G '"'.., 8/13/19 Scott Coppinger Date .. ....... ....... . ............ e v or c 1 P. C) d y'� ¢ V ) 7NN c i co p IfJ L !V!O F moo0. nPli \ N 0 H co ir. cn 3 0o w w w ro co Mao _N $'w 3 m v 0 o cp T o [[ uNi rm- °DE C N N CE zmp o v53 m CA U �rpe-�'` , 0 E. o 3 ' N c0 '�'o C a o C Q) +`+ n- 3_ ,:c m o (� C i H i- a) %, ��ppp < m L C > \, ,i,,AR UI QN c N y c f•D+ N a) 0 E = � N ocma) o d 0 • a 4 o O IV U O 0 J( tNi • DOQ ul 0 LU w LL C 00w r 0 2 0 N C : i U1C)