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Home My WebLink AboutBld-20-000815 a'ice Use my RTW/ E D P 'VT 1,57) Yic - O V� H Amount M ' s ST: AUG 13 2019 tit) Permit expires 180 days from v V issue date BUILDING DEPARTM ..._I3Y_...- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: �� '��[,('� f -�,�•}— 1.11/ S it(7 J j i- ASSESSORS INFORMATION: L1A�rc1"' / Map: Parcel: OWNER: .e/ t a / /4,6j S.s. 51 — (,l`2 _ 7( 2-" NAME�/ PRESENT ADDRESS TEL. # CONTRACTOR:�!Sr J �l _( ct �� 11 M 1'��, / �- i'C... 12.E 6—L:er .7 —g 1�G NAME ILING ADDRESS S �/'y � "YyrEL.# residential 0 Commercial /,,, /!v/n,J Est.Cost of Construction$ 1t av Home Improvement Contractor Lic.# G,t`� L•.ri.4 -�/ Construction Supervisor Lic.# C`., — y t`o ct 5 Workman's Compensation Insurance: (check one) / o 0 I am the homeowner rViam 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:# 2 ( 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: /.I.p ( `; �-4� ] S tie�S.1E-1 Location of Facility I declare under penalties of perj tha a ements 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 v of my lice d for p tion under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: —iI Owners Signature(or attachment) Date: S 1 //r� Approved By: � i Date: 7 Buildin ffi ' or d ignee) F ADDRESS: Zoning District: Historical District: r Yes 1 No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: 111 Yes No E. Yes : No The Commonwealth of Massachusetts :my '�_ '1 Department of Industrial Accidents l= 1 Congress Street,Suite 100 Boston, MA 02114-2017 wow mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aanlicant Information Please Print Legibly Name (Business/Organization/Individual): �r►-�i ✓'S 1.6 re;r. 1S S / 6, �— t i-o rv,c7- , - ►��-— Address: -� Ulu r� .i - Er1/>, City/State/Zip: c HA- 0244 cl Phone#: -3 43f- 70-0 Are you au employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.2(am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 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 a or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.O0thei c i!r�-°Y:�` t zu 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Arty 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 employee& Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:CI ?<I ;r3 4-c5 LJA City/State/Zip:5 y, -12L-i 1-.r 6-44 - 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 viol . py of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifi I do hereby - ,d, , .' of perjury that the information provided above is true and correct. Date: / � none#: ( _ J 1 - 7s 4:7 '..'� 7 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ANWA