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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department !!t -
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS:- • LW V IV 1 OUAJ l Mil 62L13
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNERJOIVEL ed15 Ma 4�( n�1 1 l W\►`�V U lXU V A I
NAME PRESENT ADDRESS #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Residential 0 Commercial Est.Cost of Construction$ 3 coo.07i
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#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove I
Siding: #of Squares Replacement windows:# rt 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: • 4e--ANS V7Z 5-1441101U
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 revocation of''/license and for prosecution under M.G.L.Ch.268,Section 1.
i� (11
Applicant's Signa, Date: 1
Owners Sign re(o chment) I46t Date: I
40;
Approved :y: ' ���!gS/� Date:
:"Ming•OW: ..-;iI EMAIL ADDRES rr 4'at I „ ' G` ,1(*,
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
..54." 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): V OI W'
Address: L55 0 1 Y
City/State/Zip: k1J1 'j3T\\1 '► 1 \ Paktne #: � (D m 44
Are you an employer?Check the appropriate box: Type of project(required):
LE I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 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. Vram a homeowner doing all work myself. [No workers'comp.insurance required.]t
9. [1] Demolition
10 E Building addition
4.E1 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.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.
r 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 certi under the pai s and penalties of perjury that the information provided above is true and correct.
Signature: ►011451 I C1 Date:
Phone#: 5C g `0,&k) 4\ 4
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#: