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Home My WebLink AboutBld-20-001356 Office Use Only 01•Y A R` a '�Yr : � r Permit# -1. aog,t ! I ty Amount /Da —O * t . H ir"ln 4'. --55)3"kft es,.Cel Permit expires 180 days from =#;,. issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ;j F 10 2019 Yarmouth Building Department H 1146 Route 28 -, South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: G!/ ASSESSOR'S INFORMATION: Map: ) Parcel: OWNER: 7ifV1 / tell le jn ck F.(NJy,,,IRE SCUYIe ? £A (2PeriNAME / PRESENTSS TEL. # CONTRACTOR: /// NAME MAILING ADDRESS TEL.# C) lResidential 0 Commercial Est.Cost of Construction$4( / GC) 9 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm '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 Replacement windows:# Replacement doors: # Roofing: #of Squares /0 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: r �r A 0 f cCc/p 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:jQ-stvners Signature(or attachment) D Ai Date: q Date: / !/, 7 Approved By: Date: / ''-1<0 7. Building 0 esi ee) E DRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft of Wetlands: 0 Yes 0 No 0 Yes 0 No —,6 . The Commonwealth of Massachusetts Department of Industrial Accidents ill _::'.1:.= 1 Congress Street, Suite 100 i= Boston, MA 02114-2017 -, 5.•s> www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly 5 Name (Business/Organization/Individual): . CDlt 7 r2q14nW-5,k1 Address: ) pia �/��- c City/State/Zip leirim e M if (� ,� 'one #: 77F �U / I U�Are you an employer?Check the appropriate box: Type of project(required): 1.111 I am a employer with employees(full and/or part-time).* 7. ❑New construction _.u am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.;2c, am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 ❑ Building addition 4.1D 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.❑ Electrical repairs or additions proprietors with no employees. 12.❑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.$ 6.0 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. 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: 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. Signatur�. J z. � Q WJ Date: / q honc _ 0 • 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#: