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Home My WebLink AboutBld-20-000526 ,YRR d Office Use Only '' (pc dPermit# r; ! O� 1' .�H Amount 5(l MATTACM FCsa, . �`°`°°""°"p d Permit expires 180 days from 1 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH lU i ', flj'1 Yarmouth Building Department 1146 Route 28 ( J\ (0Z South Yarmouth, MA 02664 —f-'/ '1 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: `4)%tcc‘ -‘1 O 1 154.1 skQRW►OJ \,i ASSESSOR'S INFORMATION: Map: Parcel: \ OWNER: �4E4. v SvUv%v4v �O ` �\A \�1 � UC► \13 . CQ.si4.CIO tA NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# ii•Residential ❑Commercial Est.Cost of Construction$ a bW'LI° Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor u 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 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 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: 444. Owners Signature(or attachment) • ' e VJ Date: %Ini 14%1yy \CS Approved By: !? Date: `— �75 Bu g 0 'al( designee) EN ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No D Yes ❑ No The Commonwealth of Massachusetts f Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 5•` 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 , s_n stein :,ni -?_' :'„a!): g1/4.V.,31.1\V00.1- Address: p'1 ��w� `•aEe�� 10 tM 113 . a4(4Lt0_0.it_, City/State/Zip: Phone #: SO%- S OS _Va..4 b Are you an employer?Check the appropriate box: Type of project(required): I.❑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 any capacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. _ Demolition y [No workers'comp. insurance required.]` — I0 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.❑ 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.= 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. 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. 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 %der the pains and penalties of perjury that the information provided above is true and correct. Signature: v Date: �• ` L1LA \g Phone rr: 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#::