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Home My WebLink Aboutbld-20-002817 .-��,�,gR O Use Only C O . H Amount f/1 i •� NATTACM ESE i *°"S°°'E°A 6,f,dPermit expires 180 days from t issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: cq �r,,-t, GL t, r i ASSESSOR'S INFORMATION: Map: I0 Parcel: 7 �1 7�j OWNER: I 0 L-P rr - vG j,_ J c D a d )h V J 7 No-1 PRESENT ADDRESS TEL. # g`„ c >' 0-5,. CONTRACTOR � � �/�NAME �� L D SSTEL� Residential ❑Commercial Est. Cost of Construction$ Home Improvement Contractor Lic.# / / 3 f Construction Supervisor Lic.# 96/3 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 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) �^�Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool�fe4ei ,l/ `t4"`0 f,p P a C *The debris will be disposed of at: 6 fiL xe-io 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 revocati of my licen d for rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature Date: e ., c g 1 7 Owners Signature(or a chment) Date: 6--e Approved By: "'fi-y Date: //`d Y//1. ilding Official(or designee) EMAIL ADDRESS. / Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No 0 Yes �U No _ _ =\ The Commonwealth of Massachusetts r1_90-12* Department of Industrial Accidents LA _ ill= 1 Congress Street, Suite 100 ' , mon_ � Boston, MA 02114-2017 0., �,�.-''� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. T¢ F D WITH THE $ I/TT 4 ORITY. Applicant Information (. c^ - (��7Z/ ( Please Print Legibly Name (Business/Organization/Individual): 3 , S 7 idg Address:/aL___� -yL��f /1 'jj /a /961.7cl C. City/State/Zip: 1v )' ie/if Phone #: 42f := 4 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a pioyer with employees(full and/or part-time).* 7. ❑New construction 2 I a sole proprietor or partnership and have no employees working for me in 8. ❑ 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 E 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.E1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El 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.El 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: _/ (1 i P1) City/State/Zip: '/ C..,e(:rl3 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 pat andpe alties of perjury that the information provided above is true and correct. Signature: Date: ✓9� /2, / Phone 4: 4 09 , ,,,, ,s,,,/z),/, 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#: 1 f Lo't' 3°1MRF8)G /? LOT NO. : EIQ ADDRESS : 89 FREEMAN RD., YMPT. OWNERS NAME: PAUL HIGGINS SEWAGE PERMIT NO. :85-129 NEW: REPAIR: X DATE ISSUED:_4/85 DATE INSTALLED: 4/85 INSTALLERS NAME R.B. OUR CO., INC. INSTALLATION OF: 4" L. PIT SLL WATER TABLE : FINAL INSPECTION BY: BM DRAWING OF INSTALLATION ON REVERSE SIDE : 8 << 2' - L I egg o3 V s • /'q / • • . 0