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'issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
1 CONSTRUCTION ADDRESS: Vq‘ 4-1411\ MAIO Si •
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: 3E.) C.COL 1 G►1 0 r1 ' A lr1 S-44 -i.1 5OE • Z. C)-c1Z\Z
NAME PRESENT ADDRESS_ TEL. #
'I CONTRACTOR: 3 EJ" Co N
L rO. 1 11 bm
NAME MAILING ADDRESS TEL.#
)esidential 0 Commercial Est. Cost of Construction$ /DO.QC)
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
G I am the homeowner 0 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 Replacement windows:# eplacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 laye- - Insulation
Nio4c Cazck) r 1, i c F
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
I O�'*The debris will be disposed of at: 11 'O - yiZ\\1 V —TV14 Si:'�11- Sri. i t 04
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 revocation of my license and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: L. < < .1A Date: \2- --)`l
Z.-Owners Signature(or attachment) Date: 1 1161£1
Approved By: /j 6/ Date: /2 /c '77'
Buil . °. 'or de ignee) EIv ADDRESS: .1 c..c,:,tvA 1 izyweo. e
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes U No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes 0 No ❑ Yes _ No
The Commonwealth of Massachusetts
' 1f /7, Department of Industrial Accidents
1 Congress Street, Suite 100
4 Boston, MA 02114-2017
°,M„5.•`'' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
I Name (Business/Organization/Individual): V,r}J C.03 L
L. Address: 1 LI \ Oaf IAA i>> Lt,.
c._ City/State/Zip:`J.Vae— X1) INA 02669 Phone #: ` 286 CZDZ
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
2.r 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. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. 12 Demolition
^^ 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.Q Electrical repairs or additions
proprietors with no employees.
12.7 Plumbing repairs or additions
5.7 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs
These sub-contractors have employees and have workers'comp. insurance.:
6.E 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:
e—Job Site Address: 1 C11 1,\II$11\ MA 10 ; City/State/Zip: 3 \INZ.1M ',1\l�yA CZ.).(,
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 cer ' u der the pains a nd penalties of perjury that the information provided above is true and correct.
E..scinignature: tt'-" Date: 17"1 6"1 C1
Phone#: 5 Da 2:-'i o - 'c
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#:
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