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Home My WebLink AboutBld-20-001586 0�•Y�R ice Use Only • dimb(O l.',� H -Amount MATTACM CSC. "Tw,,..rto0 E:,d :1 Permit expires 180 days from {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: tI g ( W I n�,O w (L R Ol SO - \f Al Ma H ASSESSOR'S INFORMATION: Map: 58 Parcel: Z 1 Li OWNER: ?(.)r(l (")o u 1A-0 r 1`i Gott" is S• OCA41%s 0 8 - IS 5' -55 3 3 0 NAME PRESENT ADDRESS TEL. # CONTRACTOR: tJ Q(v‘e.— NAME MAILING ADDRESS TEL..-# iResidential Residential ❑Commercial Est.Cost of Construction$ / 1500 Home Improvement Contractor Lic.# 162511 Construction Supervisor Lic.# S O '. O G k 4S Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name. L.\‘O( k1 ( tiOrtAat` � :-S ; Worker's Comp.Policy# W C-5 '3 k - Z 1 j 4 6 6 - CU 7,1 WORK TO BE PERFORMED Tent Duration + (Fire Retardant Certificate attached?) Wood Stove -� Siding: #of Squares 1 Replacement windows:# 3 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: M it Ll M Tc&'tl S T e Sid. ,a e ( 6 - S C) Location of Facility I declare under penalties of perj .- th. 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 o;rev,c ion of my license and for pr ecution under M.G.L.Ch.268,Section 1. CI ti c�j Applicant's Signature. J Date: i I �^ Owners Sign. re(or attac ent) Date: �J�� Approved By: �� 'Apt,111, • Building 0 ;cial(or de •n EMAIL ADDRESS: f E p 1 E D — Zoning District: C �n19 Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes Li No SFP 1 Water Resource Protection District: Within 100 ft.of Wetlands: eca--DEPAR'°' • 0 Yes 0 No 0 Yes ❑ No — — — The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 M r 5.� 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): \0 ti kA-p r' C1/4hr ccirCU,,t„ t G Address: 0\ Ci ree.t- l/;tax l0 t City/State/Zip: c: , - c Mc, 026 60 Phone #: 5e - e 3 3 ti Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.VI am a sole proprietor or partnership and have no employees working for me in 8. 'Remodeling any capacity. [No workers'comp.insurance required.] 9. — Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 ❑ Building addition 4.❑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. 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: L-- b �c / Mti' c.k =1-1Succ CC. Policy#or Self-ins. Lic,#: W L - 3 5 - 2►rj Li Ey_ v Z q Expiration Date: - 2 U Z t3 Job Site Address: S"7 U , Care'/ iz,„J( City/State/Zip: Ste. yarMc:.ckN 02. oz{ 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 ' nder the pains and penalties of perjury that the information provided above is true and correct. Signature: Pi 6)` Date: 1 17 19 Phone#: 5"0 fS - 3 Fs5- $33 Q 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#: