Loading...
HomeMy WebLinkAboutBld-20-002458 y _ Office Use Only • O1. 0.• E CC, I E0 -aOD'b p �5 0 •.l H f /4"O f d -Amount Gig.,(1 �J.;i ' Permit expires 180 days from 4 issue date !.-.DING DET AR i APEN EXPRESS BUILDING PEIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /9 B('Y' Ian an W, ,/a WI tt .1) a ,<,' ASSESSOR'S INFORMATION: Map: Parcel: OWNER: / e 14/i/0n /`/,Dlrl.4/cAtehe it Yari 0do 673 t7J-'9ff S ,z/`7 NAME PRESENT/ ADDRESSS / • TEL. # CONTRACTOR: L,i1 T/�°.j I7q 1 i r4 a`� /_a 1 idn ES 1�OJ �ocyJ .#SOa 7 76-/?6 3 Residential 0 Commercial Est Cost of Construction$ ?000 , d 0 Home Improvement Contractor Lic.# I/7 7_ 4 Construction Supervisor Lic.# ©/ Z 5i g Workman's Compensation Insurance: (check one) 0 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 J , Siding: #of Squares J Replacement windows:# � Replacement doors: # � ��9/l,Clerk- Roofing: #of Squares ( )Remove existing* (max.2 Iayers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at J?4 ' Y)Vj tn4 i-A ( o f 1 14tra Location of FNcility 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 or revoc 'on of m license d for prosec on under M.G.L.Ch.268,Section 1. Applicant's Signature: 1(_�Z� i�"' �� Date: /0 p 'r Owners Signature(or a e t) tq Date: /o K- /J Approved By: Date: ./O/2y/�! B g Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts .�1 L Department of Industrial Accidents 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): CA CI rJ' /40 ti r o Address: 2 3 tin,ot) V City/State/Zip:/arrYAAicH mQ o2'7S Phone #: fal 776:—/ t<. 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 24 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all workmyself 9. ❑ Demolition ❑ [No workers'comp.insurance required.]` 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.E Roof repair These sub-contractors have employees and have workers'comp. insu ance.t. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.f Other�� /�ty`d j 2 r C�'i 152,§1(4),and we have no employees. [No workers'comp. insurance required_] /� *Any applicant that checks box 41 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. Tn curance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: - Job Site Address: 9 ,f j(°l"C�IC-/G /-L?/I e City/State/Zip: G�: t C?1'1?l✓l414 (,Toro 7_3 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 u er the pains and penalties of perjury that the information provided above is true and correct. Cc /���c)�l�rzr Date: 1O 1,?q /` 9 Phone#: $ 3 7 6-- l a b 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): I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: