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Home My WebLink AboutBld-20-004433 Oc'Y� I '.O eUsc Only r. CEaVE ern0.20-- eD,ill Ou '47 1�s ^T g Amount '` ,, 4' "1 i 3 : MATT 1-C Permit expires 180 days from issue date 4 IL-VI• BL, NG DEPAR i ML NO i EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 , South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 f J CONSTRUCTION ADDRESS: I 11 ... �1 C. e v‘ l e ` S A / G►A.,0•Jr. I1 ci r ` ` ASSESSOR'S INFORMATION: ` Map: i 3 `Z Parcel: / ," OWNER: / 'I `1, 1- k LJi1SG 1 Iz Cr- 4e.►-SA YeArr-4 r lo ` 1- c05 -Z4) -LI153 NAME PRESENT ADDRESS TEL. # CONTRACTOR: X.i e ,- Li. (o c.-(I '-q No N1 c'T) 0 L-L y;yv 1- 5 0 737-/Z0 NAME MAILING ADDRESS V TEL.# Vesidential 10 Commercial Est.Cost of Construction$ i Z , C C C) Home Improvement Contractor Lic.# I ) Li 1 ' Construction Supervisor Lic.# C S 0Cg.50 7 I y f rS l zozv 3/Zy / Zt: 4: I Workman's Compensation Insurance: (check one) I am the homeowner/� 7 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: 4 9 Sv C . 6-1 e c -Ckyi G y p ;, Worker's Comp.Policy# i.J Ct✓cco'S'01 Z ZS't)Zei 14' WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove A hk- 1 Siding: #of Squares `' Replacement windows:# Replacement doors: # �Uk '} Roofin :#of Squares ��— ( )Remove existing*(max.2 layers) Insulation 'v`6J t Old Kings Highway/Historic Dist. ( ")Re lacing like for like Pool fencing \ 1 gP *The debris will be disposed of at: S I . t x t'0 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,ps.reveeatiea of my license and for prosecut under M.G.L.Ch.268,Section 1. Applicant's Signature: \ '.."-------- (l "- '_� 6,-1( Date: z I-1.- io Z-( Owners Signature(or attachment) 1` n, % . ��•1v-4 ) Date: ill6 Approved By: F" Date: -//— Building 0 ci r designee) MAIL ADDRESS: Zoning District: Historical District: P Yes No Flood Plain Zone: Yes C. No Water Resource Protection District: Within 100 ft.of Wetlands: Yes l=] No ❑ Yes 7 No The Commonwealth of Massachusetts Department oflndustrialAccidents :1n1— y 1 Congress Street, Suite 100 Boston, MA 02114-2017 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): . ()‘(4 C c l( ( o A)5' f i C f t r?ill 1--L-C. Address: IA 0 rt,te C c 126.Yx_d_ City/State/Zip: �/ oV‘k Qc,t �t( . OL -75 Phone#: cc16�3 7-I �.-5 Are you an employer?Check the appropriate box: Type of project(required): ItaI am a employer with 1 employees(full and/or part-time).* 7. ❑New construction 20 I am a sole proprietor or partnership and have no employees working for me in 8. *emodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work rnysel£[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 an 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance? 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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�S S Cc t G- 'Gl (_•ter f n/p l y Policy#or Self-ins.Lic.#: 4)6(.6 co S O Z Z S'C Z O iI 4 t Expiration Date: 7/9 frciz_o S Job Site Address: �Z`j L � �,� k c r }�(C- City/State/Zip: �G`1`'W c iJ14t' 0 r 4 UZ.G 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 nder the pains and penalties of perjury that the information provided above is true and correct Signature: / Date: Z/ / 2/Zu ZU Phone#: yd ler-73 7 -t 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#: