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Home My WebLink AboutBld-20-1297 Office Use Only og.Y4R s�, Permit# I .- 'l' : . y 5 Amount �— �, Ord Permit expires 180 days from issue date t u)- rzi7 RECEIVED EXPRESS BUILDING PERMIT APPLICATION — TOWN OF YARMOUTH SEp 09 2019 Yarmouth Building Department 1146 Route 28 BUILDING DEPARTMENT South Yarmouth, MA 02664 By —(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 31 7'rtau a R(D - &s 7H I G4)4,ST yA RMOt, �/yA 02673 ASSESSOR'S INFORMATION: Map: g a Parcel: z 7 OWNER: `SAE S-Nb 37 m 'J&?i `i 7/ "SDq? NAME PRESENT ADDRESS TEL. # CONTRACTOR: SA/14- /}s l4 aovE NAME MAILING ADDRESS TEL.# 44,Residential 0 Commercial Est.Cost of Construction$ 2Q3, to Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner 0 I am the sole proprietor ❑ 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: # 1, 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: yf�(ExOU]'4 (J/4'6 T e I ee.AntSfe Ie r"ACa E /'I 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 r cation my license and osec 'on under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachment) ) Date: Approved By: 111 Date: �V —Zr Building (or designee) ADDRESS: 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 r Department of Industrial Accidents rim' ' 1 Congress Street, Suite 100 s Boston, MA 02114-2017 �;5••'y 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): c,.) Address: 7 City/State/Zip: Lid k , -1,rit-o-t DZ. 73 Phone #: SD E -- 7 7U - SO 4/E 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. E New construction 2.0 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.] 9. ❑ Demolition 3. a homeowner doing all work myself. [No workers'comp.insurance required.]t I0 E Building addition 4.E 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 1 I.E Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.= 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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 cer ' nde the pal penalties of perjury that the information provided above is true and correct. Signature: Date: C ( T 9J 2O I�'-j t/ Phone#: . — 76 -.coy g 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#: