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Home My WebLink AboutBLD-20-1159 ®�j4'YR ®_�_..__ Office Use Only --7.• t y� C` E C E I i! E D _.Permit# 4. {O/� l ` H Amount _e• MAR n ['s, i !! _ '-w..... End. a AU G 30 2019 Permit expires 180 days from - :; "' issue date '!)!S_DING DEPARTMENT EXPRESS BUILDINGTERNMEAPPLICATION TOWN OF YARMOUTH iJ LI)--ap--I IV Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: j - ZS6 S. Yzei,,,avi La .IvEfe_fit>J4 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Faso ni scams ► 3 %-� ZA 6-0 o — 39 q—a 1 g,g, NAME PRESENT ADDRESS TEL. # CONTRACTOR: 1 in 'TO \1 O`1 vi s 1�Q.,h%) 9 d U— % b U—O747' NAME MAILING ADDRESS TEL.# ❑Residential commercial Est.Cost of Construction$ d 0 II-- • Home Improvement Contractor Lic.# Construction Supervisor Lic.# e....131. )' l\l /61 / t. Workman's Compensation Insurance: (check one) ,' 0 1 /4j 0 I am the homeowner I am the sole proprietor 0 I have Worker's Compensation Insurance p/a.-7//9 Insurance Company Name: 1 C1 Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares t `O Replacement windows:# Replacement doors: # 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: S• �'X(A—, -5-6'v ''IN�< Location of Facility 7 I declare under penalties of perjury that the statements •erei• ontained 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 'c. , i for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: - i Date: f5)1AVII) \C--\ Owners Signature(or• went) Aillir I Date: e% �� Approved By: _I - Art / Date: �/3 7l" `'molding Official(or.esignee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts r Department oflndustrialAccidents =re 1 Congress Street, Suite 100 • _ �= Boston, MA 02114-2017 • N.5�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): Address: 0 .City/State/Zip:ir j..,-b ,.,; iac4 0:9,6O Phone#: q'6c6 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 I am a sole proprietor or partnership and have no employees working for me in 87/E Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]` 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.❑ 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.❑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,§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. tContractors 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 and t s and penalties of perjury that the information provided above is true and correct. Signature: Date: \%4)\ 1 q Phone#: 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#: 8.30.19 Contract I,Jason Siscoe, have hired Tom Futej to Replace (1)and perform sidewall work on my storage area located at 1338—Rt.28,South Yarmouth, Mass.02664. Jason Siscoe Tom Fut •