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Home My WebLink AboutBld-20-000400 �� ; -f,YAR : Office Use Only �� ^� ,1k �t yffik ! C ' I�o(D'-.mot'W _Permit# O l . H Amount Q0u .`°"'°...."cod '?Permit expires 180 days from ,: issue date EXPRESS BUILDING PERMIT APPLICATION t, ,, ,r,,, TOWN OF YARMOUTH -_.• Yarmouth Building Department 1146 Route 28 U -19 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ene S 1 / 1 ( 7r)0t / Q� I.1 7 0 e 7J ASSESSOR'S INFORMATION: 7 `C Map: Parcel: /n►,�, OWNER: '�l le, f Ci.c( Q (Olt -'cl c NAME PRESENT ADDRESS TEL. # CONTRACTOR: �r FP NAME MAILING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ 3 Vv(p / W Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# 60- () I- I DD•6t- WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove w Siding: #of Squares _ Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove e ' mg* (max.2 layers) Insulation IZ Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing *The debris will be disposed of at: ''Cr---Yb1 i , er tr /( 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 deni or revocation of m icense and for prosecution under M.G.L.Ch.268,Section 1. - Applicant's Signature: , Date: �E✓(''L 2 ? Iv(? Owners Signature(or attachment) Date: Approved By: Gt G Date: / —'/ B ina cial or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts Department of Industrial Accidents ' l 1 Congress Street, Suite 100 /►� Boston, MA 02114-2017 IMP 5'•`''y www.mass.aov/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): A , LCa/ Vl- 6 _ Address: 10.-� , f 4( 4(l City/State/Zip: Cd, `� C� /1/, - Phone #: ® 7 7 5-) 19x— - Are you an employer? heck the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. E New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any ca ' .[No workers'comp.insurance required.] 3. a homeowner doing all work myself 9. E Demolition y [No workers'comp. insurance required.]` 10 E 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.❑1 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.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. I.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 under ze pains and penalties of perjury that the information provided above is true and correct. Signature: U k/1 Date: 61---71 A-°( �( Phone#: 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: