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Home My WebLink AboutBld-20-001612 si,, Use Only °1� o - 0040- aQ - /(a Ow H Amount .. M tom•• L°l ' Permit Ires.)$ti-As Itivr . �:• issue date EXPRESS BUILDING PERMIT APPLICATIONS ;j 1019 TOWN OF YARMOUTH Yarmouth Building Department i 1146 Route 28 South Yarmouth,MA 02664 `�(50y8)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 9 e V Q l /c rY"�^" "�' L mil--ASSESSOR'S INFORMATION: 6 Map: 3 Parcel: ti OWNER: Roe. T- O tk vizInck_ eNan ,, -+ Dce- I aLi NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL./ # yl Residential ❑Commercial Est.Cost of Construction S of f'pc) Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor 0 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 lb 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: vim, eyW `l c" ' 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 answers) 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: / Data T Owners Signature(or attachment) Date: Approved By: Date: Building al ignee) EMAIL SS: Zoning District: Historical District: a Yes ;-1 No Flood Plain Zone: Yes r No Water Resource Protection District: Within 100 ft.of Wetlands: r-1 Yes Li No L Yes U No . The Commonwealth of Massachusetts l =.-1 1=A/ Department of Industrial Accidents ct =e:/II_ a 1 Congress Street,Suite 100 VL_e Boston,MA 02114-2017 *4r,47~ 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): g Q, I C)/e 1 wuriCA. Address: '- e\..2,.. c-isi e_iy..,v`. s4 - City/State/Zip: 5 Af CAA y-yl OlJ`CA.- Phone#: - -4L4 - , I c-.*, la Li Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.!d . sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling c parity.[No workers'comp.insurance required.] 4 ►,)I am homeowner doing all work myself.[No workers'comp.insurance required.]t prt 9. ❑Demolition 10 ❑Building addition .lir§ 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.; li.❑Roof repairs 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.Lie.#: 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: X 7/unl_,(2'e-gns 2� Date: o f q j 9 Phone#: fl 1 aqa L5214. ' 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#: