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HomeMy WebLinkAboutBld-20-001277 Office Use Only 1 of.Yo' Permit# • a 0 . y Amount t MATT M [SE 1 Permit expires 180 days from -=: C01issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH i ^ ,: CFIVE. Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 • I. ' �� ' (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: // 6� (f ku.co.L� - - ASSESSOR'S INFORMATION: Map: l /Q Parcel: �iOWNER: G�f ��'L A, •l�/e `l UCA-L/1-�0!bl� A-6 5oa —7 G —/l° to NAME S ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Cif Residential ❑Commercial Est.Cost of Construction$ 2_© C O Home Impprovement Contractor Lic.# Construction Supervisor Lic.# Workmar�'s 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 Al Replacement windows:# Replacement doors: # Roofmg: #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: //^1 /�--l''1 v UT(� UL/v L f• )r� 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 ti of my license and f prosecutio under M.G.L.Ch.268,Section 1. Applicant's Signature: i,. Date: Owners Signature(or attachment) /4 ' Date: Approved By: r ' " Date: b/ ', Building Offic. (or ignee) E DRESS: 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 1=W, — 1 Department of Industrial Accidents _nal= 1 Congress Street, Suite 100 • _' �- Boston, MA 02114-2017 -�M— `'y www.mass.aov/dia ... b Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/lndividual): A 4.6 X 11 iif e'/ / Pr e/' Address: /` Mj eAK=f4 i ti©o b R., City/State/Zip: 7A12110a17 )/10 Phone #: 50;i —7 4-6 -- j6 y7 Are you an employer?Check the appropriate box: Type of project(required): LEI I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.12 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling an 9. ❑ Demolition capacity. [No workers'comp.insurance required.] 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.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.12 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 i)/ <G C �/4 -e r -lJG LC 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a S r 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 andpenalties of perjury that the information provided above is true and correct. Signature: , �/L-f-s.,',� A: 1, / �4-`2e--f. Date: Phone#: 'Ife -- `"I 7 - 7/Q9 i( --./ 9 ��� 71�n / 7 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Afx,47(?) A__A y 9 1/1/ ,�) e o fr . /1//9.- D/q 2/ seP 2, / j d wti 4�- i Dvt i((- `/ I6, -"- Z E , dZG V//72'("6c26t7ttr 6 g C .� /.aok��G f a��v�-.�� , 'lam v�.�'�V /- 71/Jrc