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Home My WebLink AboutBld-20-000508 ,YRR Office Use Only (O/� � ''it . �] 1 Amount MATTACn [SE -7 �`°"'°'"{O''EL`i 1Permit expires 180 days from ,.issue elate, _ RECEIVED EXPRESS BUILDING PERMIT APPLICATZ I N TOWN OF YARMOUTH JUL 2 9 2019 Yarmouth Building Department 1146 Route 28 BB '��'EPARTMEn South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: t APtaGaea/ L N • w YRMOi '& ASSESSOR'S INFORMATION: n� n Map:y n1 C�f�Parcel: OWNER: L-Tutg>om I / u•-01-0V 1 1 SI NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# 01/4.1 Residential ❑Commercial Est.Cost of Construction$ 700• Home Improvement Contractor Lic.# Construction Supervisor Lic.# Work.mis Compensation Insurance: (check one) 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: # 3 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the statement i -r:n contained are tru 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 lice .e ,!d fo prosec ion der M.G.L.Ch.268,Section 1. / 72-q/ tl Applicant's Signature: /� Date: / Owners Signature(or attachment) Date: Approved By: Date: / Building Off (or nee) EMAIL ADD SS: 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 1 * IL Department oflndustrialAccidents 1 Congress Street, Suite 100 S. Boston, MA 02114-2017 °1M 5�•`' www.mass.gov/dia IMP Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Ly�Name (�„G:ress,,, --iT , a .). 641a I(Z VW..Gr010V Address: 2 Jl(SIGQ )...!J City/State/Zip: l d/ , y C(21,4o44\ Phone #: 72( qp1 02.51I/ Are you an employer?Check the appropriate box: Type of project(required): 1.El lam a employer with employees(full and/or part-time).* 7. New construction 2.—I am a sole proprietor or partnership and have no employees working for me in 8. 7 Remodeling — g any capacity. [No workers'comp.insurance required.] 3. am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. _ Demolition 4. my property.I am a homeowner and will be hiring contractors to conduct all work on I will I O _ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E 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. 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.E1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ig.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. ;Contactors 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 un r 'ze pains an penalties of perjury that the information provided above is true and correct. Signature: Date: 7772 7/ 6 I - / Phone#: L( 1 4 2N 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#: