Bld-20-000529 Office Use Only
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: & 75 �"� L..c‘ t Ya4r 10 o%, /NAPS "�/
ASSESSOR'S INFORMATION: ( 57' cn'`�v vU
Map: 7 Parcel: 5/7
OWNER: T1r\o c•,.a S 0 Q- c•4tr.' )5 CA.,exc l ,R$A- 13 )—fo131
NAME PRESENT AlODRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction$ / '" (f
Home Improvement Contractor Lic.# _ Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
IIK I am the homeowner ❑ 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 3 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: /p ...
J 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 1.
Applicant's Signature: Date:
Owners Signature(or attachment), '<) Date: "i k 30\` ck
Approved By: ..G Date: 7 — 3 U—I`i
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
'\ The Commonwealth of Massachusetts
_ Department of Industrial Accidents
=�,e 1 Congress Street, Suite 1004 cm: �- Boston, MA 02114-2017
.,,,, — .„,> 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):
Address:k -S C cc�,1 cy
City/State/Zip:, * csM.c i !vf Phone #: 508-131 '4=A'J)
Are you an employer?Check the appropriate box: Type of project(required):
1.0 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. I am a homeowner doing all work myself. 9. El Demolition
_ y [No workers'comp. insurance required.]
10 E 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.E Plumbing repairs or additions
5.❑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.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other S t 1 el
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.
r 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:e( 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 and penalties of perjury that the information provided above is true and correct.
Signature:'( -k• °,.,.„ ati C . _ Date: i `'NA\C••
Phone#: ,•- 1 ci-613i
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#: