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HomeMy WebLinkAboutBld-20-000615 - Office Use Only I,,Yr O Permit# t 0 _ ' '1•'► . 1-3 Amount ` MAAVT'�[��, E, Permit expires 180 days from issue date �,1� ?o-,Is- RECEIVED EXPRESS BUILDING PERMIT APPLICATIO, TOWN OF YARMOUTH AUG 02 2019 Yarmouth Building Department 1146 Route 28 BUILDING DEPARTMENT By. South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 99 S u.,t r r el iR t* CL-P M®u Pe, 14 A 1) ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1 Imo— f ( Y1S aCi 5, Li!1re--1 lR u-A 5D .' a Loa a605 5 NAME SS TEL. # CONTRACTO : NAME MAILING ADDRESS OD 63,2 Z TEL.# crC) Residential 0 Commercial Est.Cost of Construction$ I p ann. xx-- Home Improvement Contractor Lic.# 1 A `+ Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) %I am the homeowner ❑ I am the sole proprietor 0 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 el, Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation 9 Old Kings Highway/Historic Dist. (k6 Replacing like for like Pool fencing *The debris will be disposed of at: 5 °i"3 E X CO Tr)(. z©o &r UJ e& A Pc. 5 _ 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 revo • n of my license and for pros ution under M.G.L.Ch.268,Section 1. Applicant's Signature: GfrfrX / Date: P/2-/,-AV Owners Signature(or attachment) Date: gl.A/2i7I Approved By: 1— Date: % — ' -1 CI • Building Official(or designee) 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 0 No The Commonwealth of Massachusetts _W ---= Department oflndustrialAccidents 1 Congress Street, Suite 100 _ �- } Boston, MA 02114-2017 w 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: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): I.:I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. E 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 11.0 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.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 6.0 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: 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: f' ,iC j`c ��... Date: �/vi�0/`/ Phone#: 5—Pr- 3 Z � 5 • 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#: