HomeMy WebLinkAboutBld-20-003027 Office Use Only
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1 issue date •
EXPRESS BUILDING PERMIT APPLICATION -
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 ''
South Yarmouth, MA 02664 � I�
(508) 398-2231 Ext. 1261 fS
•
CONSTRUCTION ADDRESS: I k Q—
ASSESSOR'S INFORMATION:
Map: II Parcel:
OWNER: - Sol•rnol Icy i W1L 52F-3` GZgd
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
/Residential
NAME MAILING ADDRESS TEL.#
0 Commercial Est.Cost of Construction$ f I -) , C . '
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workmayis Compensation Insurance: (check one)
I am the homeowner 0 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 Replacement windows:# 2 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: VL(koldLuv \.- `",
Location of Facility
I declare under penalties of perjury• at the statements herein co ained 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 rev ation of my .,-nse and for rosecution under M.G.L.Ch.268,Section 1.
)c- Applicant's Signature: / jil
Date: //`QS�/9
X Owners Signature(or attar£'ent) Date: t/1iS`/I
Approved By: Date: /`^2,5-77
Buil ' 0 (or esignee) ADDRESS:
Zoning District:
Historical District: 0 Yes ❑ 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
f Department of Industrial Accidents
=tee= 1 Congress Street, Suite 100
cfti- Boston, MA 02114-2017_
'• MEP 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): _7,�, ,,,40,5/ /
Address: 1, w1d Li,‘, JJ
City/State/Zip: ( 4 02673 Phone #: $ t 32f'—‘2-7
Are you an employer?Check the appropriate box: Type of project(required):
1.E I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I a sole proprietor or partnership and have no employees working for me in 8. Remodeling
capacity.[No workers'comp.insurance required.]
I a 3. m a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. ❑ Demolition
10 ❑ Building addition
4.E1 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
5.0 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.:
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.
: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 nder the p 'ns and penalties of perjury that the information provided above is true and correct.
Signature: 144114 Date: ///2S//7
•tPhone#: 6- 1,f.- ;1y-c2yv
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#: