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HomeMy WebLinkAboutBld-20-003195 0-T Office Use Only • Permit O . y Amount /OD-- �MATTA M CSC 6 � ),\.00.1.cad Permit expires 180 days from "issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department + ± ! ' 1146 Route 28 South Yarmouth, MA 02664 Cg4 11aa /�� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: & Z 1AS f 1 Y1 S() .XL t/0t/P l'v t k) ASSESSOR'S INFORMATION: Map: Parcel: OWNER: rw'l t� ((4ui. 16 itz i r !IC J< vN ty.) 41, AA" + 7 ' 3 'got, NAME PRESET ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est. Cost of Construction$ /0 / 0 O U --- Home Improvement Contractor Lic.# Construction Supervisor Lic.# 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 J® Replacement windows: # 3 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: Location of Facility I declare under penalties of;-di that the to ents 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 denia ur r ati l cense and for prosecution under M.G.L.Ch.268,Section 1. 1 J 4 Applicant's Signai Date: / l / Owners Sig ature(or ttachme t )41rj. �t Date: �tttJ y Approved By: re: /Z •"1 Build' rc' ignee) EMAIL ADDRESS: C L�,'_ << CA, cy, IT, 'I,.' ,L�' l Zoning District: Historical District: 0 Yes 'C No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 2 No Fo3er Ci -�io II Is ).ern r� Wes-Wood &A bl 4 U The Commonwealth of Massachusetts ' Ai'*:_ _ /, Department of Industrial Accidents e_ 1 Congress Street, Suite 100 `_ Boston, MA 02114-2017 •0, 54,�° 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): (<.�'C e.I �.'`A. 1(' / 6 --rri'� Address: 1 k`i0 V rya (LI ' City/State/Zip: w@ 5 rci'' D ' Phone #: t� �� 1 c co Are you an employer?Check the appropriate box: Type of project(required): I.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.1=1 I am 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 ❑ 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.E 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. 14.❑Other 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 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-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 rI tify and t e pains and penalties of perjury that the information provided above is true and correct. Date: jZ--/�// 5 Signature: A Phone#: 5-) A ' (It%/ ' 'ci(i'' 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#: 7 L., 414' -; )1-- LA)../1 in7 t y cie I 0 0A-1 Y1 .frikttA /UM'Ci v 4' 5 C t/16- 11 IT