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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261`
CONSTRUCTION ADDRESS: 3(0Z �\Z�� \Q • S.ll?...v t_�`..
ASSESSOR'S INFORMATION: l
Map: Parcel:
OWNER: SZ S�1re., LLC 5 \, 2 (` ii tee.
NAi PRESENT ADDRESS ( TEL. # /
CONTRACTOR: )v�:.�c? Q G• jbC .. a,,_G4, � qt.,?. 026 3L G� 7- 6 4( 7
NAME MAILING ADDRESS TEL.#
4C
'Residential 0 Commercial Est. Cost of Construction$ '3 LO X -—
Home Improvement Contractor Lic.# 16 4 S—t 4 Construction Supervisor Lic.# 0 14 3 Liy
Workman's Compensation Insurance: (check one)
0 I am the homeowner fyr 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 o 1 ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing
*The debris will be disposed of at: `aW" C '01./ iki, "4 3'`
Location of Facility
I declare under penalties of perjury tha'(i.- tatements 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 revocat to• . ense and or. osecution.- der M.G.L.Ch.268,Section 1.
Applicant's Signature: �� , rrftiv Date: It-10 1
Owners Signature(or attachment ,r. ,t -I/ i I, f Date: (t- l0 r1 /
Approved By: ,� � t c__--.- Date: ////)///y
Building 0ytal(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft. of Wetlands: e 1
0 Yes 0 No ❑ Yes 0 No
` ...\ The Commonwealth of Massachusetts
Wes_ Department oflndustrialAccidents
l'el= 1 Congress Street, Suite 100
o =" `= 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 Please Print Legibly
Name (Business/Organization/Individual): C �2\, :L1
Address: c+ .L. v.. aU(-
City/State/Zip: `s , ( &?O Phone #:
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I a employer with employees(full and/or part-time).* 7. ❑New construction
? I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8• ❑ Remodeling
3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
4.❑ ProPe I am a homeowner and will be hiring contractors to conduct all work on myI will 10 ❑ Building addition
�'
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Elec ical repairs or additions
proprietors with no employees.
12.E : umbing repairs or additions
6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[2 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.❑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.
r 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-contactors 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 . . • .. -nalties of perjury that the information provided above is true and correct.
Signature: ` Pr / 11-l'c -1 5
Date:
Phone#: Or_•.77( 41
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#: