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Permit' expires 180 days from
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EXPRESS IT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 67 ((f/ 4v/,j41 5c) � r44w 17 A .
ASSESSOR'S INFORMATION:
Map: Parcel: j
OWNER: -,.1 1 f 5 f. `E� 41,/ ? LP 7�GI7JTuL i 4V /rV,l i�"N T a
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: ( //?f (60/fd/✓ i.)3 le4,/vs /' 7t--A A,2 .$o ya r 5—Def-'26 7—` 6)d
NAME MAILING ADDRESS / TEL.#
-residential ❑Commercial Est.Cost of Construction$ / p i Orli .
Home Improvement Contractor Lic.# /9 J � -2 b Construction Supervisor Lic.# C,.5 - 0 i(/
ce-12
Workman's Compensation Insurance: (check one) /
❑ I am the homeowner ❑ I am the sole proprietor s have Worker's Compensation Insurance/
Insurance Company Name: 4550 c / c,--I'4� C Mid 7//Cjorker's Comp.Policy# /.'J ((5 e3 S b /9 22 0 c��
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 3- 0 Replacement windows:# / Replacement doors: # 3
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: V, CA/Ai/ ya /MLoca 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 o revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. C;
Applicant's Signature: U Date: //' 7///
4
Owners Signature(or attachment) A ,,i 1 Date:
Approved By: -/ 1 Date: /r-- 6 -
/7-
Buil , .. t (or•.-signee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
The Commonwealth of Massachusetts
rL Department of Industrial Accidents
I 1 Congress Street, Suite 100
p �, 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 p ( Please Print Legibly
Name (Business/Organization/Individual): ,SGn2Q Jo((q% S/, t5 L4C
Address: ``
3 W Gt i i,,S Pe,-Ly► o-c)-
city/statezip: Sc yaimm,,(--trA ' ' Phone #: $& 16 7-5--
Are you an employer?Check the appropriate box:
Type of project(required):
1. i am a employer with ' employees(full and/or part-time).* 7. New construction
2. I am a sole proprietor or partnership and have no employees working for me in
8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3.[II am a homeowner doing all work myself. 9. ` Demolition
❑ y [No workers'comp. insurance required.]`
l0 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑ Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E ROOF repairs
These sub-contractors have employees and have workers'comp. insurance.$ / /n
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other (/�/��'`WS / //US
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 cm employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: -5`X)C i a-r-(J1 c vly((J 1/ -(
Policy#or Self-ins. Lic. #: W (C SO r0 1970. I //4 Expiration Date: J1,/6///5'
• f
Job Site Address: G 7 (2 (t1 t ii f`l ,So lai%Pet/M City/State/Zip:" 0c G
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 verific 'on.
I do hereby cer fy nder t e pains and pena ' of perjury that the information provided above is true and correct
Sitmature:
Date: /// ///
Phone#: S-z)a-_ —S D 76)
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#: