The URL can be used to link to this page

Home My WebLink AboutBld-20-004105 .O�.Y`LR _� orrice use only r H —� FN�/�//VJ/�/l/ Amount �0 077) 4`°"k 4.'0"`0 c1c7 FEB t �_ ?07 �/ Permit expires 180 days from r- a 1 I issue date BUILDING DEPARTMENT s By I EXPRESS BUIL ) 1 ' "I PPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �j , (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /°R / '4' r< ,ir y/Y?/1 d Q7A"/C?7 /�� ASSESSOR'S INFORMATION: Map: l2 3 Parcel: /2 �i r OWNER: ()O`I V O(I��l�/. / �j o Z. f'%I/4i/�S foe +0/ o-J 7 d'' NAME PRESENT ADDRESS TEL. # CONTRACTOR: r$ le NAME MAILING ADDRESS TEL.# fZiesidential 0 Commercial Est.Cost of Construction$ 2� C Cr' Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm 's Compensation Insurance: (check one) VI am the homeowner E I am the sole proprietor J I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# ll WORK TO BE PERFORMED ��fi 7, Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ‘ Replacement windows:# Replacement doors: # Roofingg�:, #of Squares ( )Remove existing* (max.2 layers) Insulation tAllA "iOld Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Y41)C°41 it /f 4/ / Ar Location of Facility I declare under penalties of pe ' t the statements ere. contained are true and correct to the best of my knowledse and belief. I understand that any false answer(s) will be just cause for denia r rev ti y e for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: '2,(,c 40 Owners Signature(o attachment) Date: .2.// /2 Approved By: Date: - 11 - 4.0 Building Official r designee) ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: D. Yes 2 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No ❑ Yes _ No The Commonwealth of Massachusetts r 4.'} , Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ��..,Iwo www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): 16,/t) 0 C`''1/A"f, Address: '3O /-1/t1/.).e ;fJ City/State/Zip: 41/4c4-'7,g" ,y `"A7 Phone #: ScJ c o/ c 3 jc Are you an employer?Check the appropriate box: Type of project(required): l.�I am a employer with employees(full and/or part-time).* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] � 9. E Demolition 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 10 Building addition 4. t/ 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.E Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.i 14.0 Other ri/J 6.❑We are a corporation and its officers have exercised their rift of exemption per MGL c. �Al/ 152,§1(4),and we have no employees. [No workers'comp. insurance required.] S//%,ot� *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. 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 fy n er th p ' s d penalties of perjury that the information provided above is true and correct. Signature: / a/'Ja o Date: 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone, :