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Home My WebLink AboutBld-20-001294 J" Office Use Only ,.,.of•�r Y;• " ' C: Permit# / '— �/l1'y '� Amount S v i ` MATT lM LS[•�'1 3 - �°'"'°L° c��' r Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION Fri C £ ._ , TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 SEF 09 2019 South Yarmouth, MA 02664 , /. ? 1 Cr(508) 398-2231 Ext. 1261 _ ..�._ ..�_._ CONSTRUCTION ADDRESS: Li 0 P1n t S t ASSESSOR'S INFORMATION: Map: Parcel: OWNER: a Fre - c,t li 02- Pin c. 5- 7612/z 7/ , 0 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# O Residential 0 Commercial Est.Cost of Construction$ 45.---v- 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 3.0 ( O)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: *6 7 'C 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: C �(7 Owners Signature(or attachment) ` � Date: 9/ // —( Approved By: Date: 7 ..rBuilding Offici r ignee) E ADDRESS: .7 , b e'F e. �M Q 1 /,t O h'1 Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 _=P= Boston, MA 02114-2017 °M�; 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): ‘I) Fr G Address: 1/c' 2 / City/State/Zip: �p��a."-� o,"1� / a G Phone #: ? y / 2 / ?" Are you an employer?Check the appropriate box: Type of project(required): LEI I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.1]I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.Tram a homeowner doing all work myself.[No workers'comp. insurance required.]t 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.E 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. 40f repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑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_ 1 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: V° 1 A�'1 C J City/State/Zip:JO to tr7` // D Z y 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 u er the pains and penalties of perjury that the information provided above is true and correct. Signature: �� Date: !/Y / c/ Phone#: 7 ? if .2/ 2.--./9'° 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#: