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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH E ,
Yarmouth Building Department
1146 Route 28 PZIF Aso"
South Yarmouth. MA 02664
/�(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: i/0 Art!/L /� e. a,75 cw
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: k.), ,v,1,✓,t " / 46., Xve AS'S f 4V6P� /-l�l2-5 'a2 a20-
NAME ( PRESENT ADDRES TEL. #
CONTRACTOR: .__Da✓!GC Ar et i a2v ,tb'``c E 4o X:p. .S"--07 YDti -u'ar' (7
NAME MAILING ADDRESS TEL.#
"Residential D Commercial �y� Est.Cost of Construction S
l J Home Improvement Contractor Lic.# ' Construction Supervisor Lic.# CS— 0'76 '5
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor e I have Worker's Compensation Insurance
Insurance Company Name: G f>.c5 k /Gat i Worker's Comp.Policy#Ave' Wi 7 >?.Sr..,e0 fA
WORK TO BE PERFORMED ,V. ' — ila,00 ea
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows: # s 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: tt O(/
74
Location of Facility
I declare under penalties of perjury that the sta ents 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 evoc tion m ,cen 4ir d for prosecution under M.G.L.Ch.268,Section 1. A,/7
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Applicant's Signature: iiet' Date: /0 L
Owners Signature(or attachment)��y�— C/ Date: l .?
Approved By: „i-��,. y Date: il — -1-I i
Building.Official(or desi, ec) EMAIL ADDRESS:
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Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No
I Water Resource Protection District: Within 100 II.of Wetlands:
Yes No Yes No
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The Commonwealth of Massachusetts
>I� _�, Department of Industrial Accidents
_eE/Il_ 1 Congress Street, Suite 100
f Boston, MA 02114-2017
www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information , Please Print Legibly
Name (Business/Organization/Individual): eC v c �`-�s 4e;)
Address: 'O At/a-t
City/State/Zip: 1)l ir—PUo v pp 00Z/tic( Phone#: �S 7 ?d Y ?
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with tf employees(full and/or part-time).* 7. ❑New construction
2.01 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. 0 Demolition
3.0 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.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§I(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: 6: -t f 74- del e-e-c S _
Policy#or Self-ins.Lic.#: W�` YG4-(Oci 16S-o2/.4 Expiration Date: "04A4:31aU
Job Site Address: /2 4 /t,4(1 e City/State/Zip: ,&rf - G((4 01,;e66 e(
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 under he pal nalties perjury that the information provided above is true and correct
Si ature: Date:
Phone#: � O� `roc
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#:
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