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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 ( 21
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South Yarmouth, MA 02664
}} (508) 398-2231 Ext. 1261 C is a
CONSTRUCTION ADDRESS: I { �VI �� i�'ct.ci ' Sok, Itieokw'h' f
ASSESSOR'S INFORMATION:
Map: Parcel:
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OWNER: L.t� �� s� �`u5�c I I I JIV,it, J4! S Vb ,SCgI g 5
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
(Residential ❑Commercial Est.Cost of Construction$ 35-0U.
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
BI am the homeowner ❑ I am the sole proprietor C I have Worker's Compensation Insurance
Insurance Company Name: JaW Ti dt z-4/4e-< Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 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: (/(A`'i1lok.,hi 6i
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 revoca n of my icense and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: / ` Date: /L /7 C G'/ c/
Owners Signature(or attachment) ,.7 Date:
Approved By: Date: e.„2
Bui g 0 dial(or designee) TAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes ❑ No ❑ Yes , No
L;✓t CUB 9✓140 e V.e✓' 20/),✓)e T --eiM & (�f
The Commonwealth of Massachusetts
, Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
°��,�,5.•'4 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): i�l4l# t`cg�!r
t
Address: / jtrc'-Lbl.c /u;,-,
City/State/Zip: jcg,4, C14,04„vf1/4,. dv✓j" Phone #:
Are you an employer?Check the appropriate box:
Type of project(required):
l.❑I am a employer with employees(full and/or part-time).* 7. E New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp. insurance required.]
3.Va a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
m
4.❑I am a homeowner and will be hiring contractors to conduct all work on property.mY I will 10 ❑ Building addition
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
b.❑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.❑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-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 certify un r the pains and penalties of perjury that the information provided above is true and correct.
ignature: ,� ��( '� Date: / Z / f
� J
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#: