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Home My WebLink AboutBld-20-000809 ;, � Y _ �____- a:ice Use Only y $� * RR` • _7-: [ RECEIVED .„,e,- . - ou - H 1 r Amount 7000 .1 .:` NATTA n [st AUG � 2 tl .1 - `�,J♦ '.A (� lj i ll ,ch ;�Permit expires 180 days from MOG 6� M b - #;:=-:•" ' - issue date - 1.5 EPAR T Bahrtilk Y - — EXPRESS BUI DING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /L1 /0 G a L G -0_as ASSESSOR'S INFORMATION: Map: 9 y Parcel: 99 )� !� OWNER: t �.J�- i'"�- 11-Z / y 4./0L-0 V 774 q q Nil NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# t Residential ❑Commercial Est.Cost of Construction$ 1W� Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman t ompensation Insurance: (check one) jI I am the homeowner ❑ 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 yam (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares b,- T 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: \il,. tA4 t\ O J I ).-e 51 0 4- , Location of Facility I declare under penalties of perjury that the t m is 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),I:1 en e for pros ution under M.G.L.Ch.268,Section 1.Applicant's Signature: > ��X Date: SIi(2 I+ q Owners Signature(or attachment) Date: Approved By: Date: 62—/2 /7 Building Offi ' si ee) EMAIL ADD 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 Department oflndustrialAccidents ve= 1 Congress Street, Suite 100 4.4_1-_ 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): 1`*Lk(SOP.I / 'iA !..O V Address: 02. t _a-+ _R L�,1- , Al • City/State/Zip: UV , YaR ► O2-6 Phone #: 77 O 'L I £f 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 y capacity. [No workers'comp.insurance required.] 9. ❑ Demolition 3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 Building addition 4.0 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.❑ 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.i )), 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�ther ` A." 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. Tnsurance 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 the ains penalties of perjury that the information provided above is true and correct Signature: Date: g //02.-/t9 Phone#: / II( 9 )1 Ts i l 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: