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Home My WebLink AboutBld-20-002689 k°�.Y�R-7 • k40 - �Q -00- 11, _ H !Amount %), ,,,a,�,.0`- Permit expires 180 days from �� {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH '�~ ,,,, ,., Yarmouth Building Department 1146 Route 28 N, d' ' L South Yarmouth, MA 02664 �,y60 508 398-2231 Ext. 1261 `'Z -�j ``T 10 CONSTRUCTION ADDRESS: /-/ AJ��&7 P-_p ASSESSOR'S INFORMATION: Mapes N Parcel: OWNER: 1 � .._ T. )ELSa ) / L 1 Il S�( 98 7 7 —7c NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ ZO 'CZ) Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm s Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance C mpany Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 2.75. Replacement windows: # ,j Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( t4'Replacing like for like Pool fencing *The debris will be disposed of at: 137 -S,Ivi 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 revocation of my license and r prosecution under M.G.L.Ch.268,Section 1. �J Applicant's Signature: t. ,Ado . 77-87 Date: r p /81 // Owners Signature(or attachment) ,� ��;(/" Date: f I/ l/ Approved By: ,..../..4 - Date: II 'S-I `I Building Official(or designee) EMAIL ADDRESS: Zoning District: • Historical District: 0 Yes VNo Flood Plain Zone: !Yes '❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes f No 0 Yes 4/No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ^� ,�,5�•`''y www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information AI6-oro Please Print Legibly -7Name (Business/Organization/Individual): f - Address: 1/4LT l)R U k city/statezip:wrsy yoytiourif02Q5 Phone #: 565- 775T2 26 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. E Remodeling any capacity. [No workers'comp.insurance required.] 3. ,/I am a homeowner doing all work myself. 9. Demolition❑ Y [No workers'comp. insurance required.] 4.❑ myProPern'�I am a homeowner and will be hiring contractors to conduct all work on I will 10 Building addition 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.El Roof repairs These sub-contractors have employees and have workers'comp. insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.5rOther 5 / 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. 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 certi under the pains an penalties of perjury that the information provided above is true and correct. Signature: e w( //i Date: 1116115 Phone#. 5o3 775 l O 6. / 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#: