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HomeMy WebLinkAboutBld-20-002677 O� Office Use Only $ `� • - 77 0 °yis� . H Amount nwri N [st �, 1-'''',. -,_ "` °orate"',t.d' NOV 'Permit expires 180 days from s 4.i9y9. . - ..40tvr- :issue date - EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 I(3 ,CONSTRUCTION ADDRESS: !�✓s igaCtu�,�c..(/'- a fi!✓- 0 J ASSESSOR'S INFORMATION: Map:es n Parcel: OWNER: ,��"'��( 0 eA 6!/�' NAME" PRESENT ADDRESS cL v.r` , TEL. # CONTRACTOR: I S Ø. ,/ opo-f "% - r0.6ok 737 .' SA 360902 ? NAME MAILING ADDRESS TEL.# M'Residential ❑Commercial Est.Cost of Construction$ tJ -(2.-- Home Improvement Contractor Lic.# J7723 Construction Supervisor Lic.# CS 1 0 5 1:Q Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name: ', 6/1t' /M Ca Worker's Comp.Policy#tote4 5700 Sol 92 a22iq A WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 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: /3V J (2 "/ StiSfo s‘e- ` 4r f f c C-1 OR ) 4'1 2 . r0 Location of Facility I declare under penalties of! i at a 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 dem.. -1:,oca�';� of my license and for prosecution under M.G.L.Ch.268,Section 1. � I o - � Applicant's Signature: � Date: Owners Signature(or attachment) Date: I ('' 14 1 Q Approved By: t_. Date: 11 - : "'1 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No 0 Yes 0 No , A\ The Commonwealth of Massachusetts • Department of Industrial Accidents iMA,=.. I Congress Street, Suite 100 •_=14= Boston, MA 02114-2017 �;�•`''4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ,Pllease Print Legibly Name (Business/Organization/Individual): / �S g L.) 'AN (�d) I2& 1A-c ,-iti4-6) Az . Address: ) I - �( 2' W - V City/State/Zip: 1 q 1/14- 0007 3 Phone #: 5128 36© gi92 37 Are you an employer?Check the appropriate box: Type of project(required): 1.3\I am a employer with I 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.] 3. I am a homeowner doing all work myself. 9. �,�.' Demolition ❑ y [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 repairs These sub-contractors have employees and have workers'comp. insurance.: 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 atr rhed 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: ,4 " gr&-,0 �Nc o ' Policy#or Self-ins. Liic. #: WCZ- 31:12 cl2' co 5-6 oto l `f ,+ Expiration Date: 0 ql/D/ZD Job Site Address: / 3 in C7 lsl//l'rj (7.2p(.1/G.-� City/State/Zip: y/0149(4717144-026 73 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 herebycertify"-, ' t� he, • and penalties of perjury that the information provided above is true and correct. Sienature: �: Date: 0 - — Phone#: ,F6A ga 3 7 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: