The URL can be used to link to this page

Home My WebLink AboutBld-20-1842 • Office Use Only O . '1 . H Amount Its:�,"°"^Mato"':rd '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: 2 ix,�`! , i c/Nt ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1'\eAlikk PI QA A n,. I mi,.•11 F!7ttC.et i)n !)�O'(''' -32 31l(r{ 46 NAME PRESENT ADDRESS TEL. # "� I I.' CONTRACTOR: L. // NAME MAILING ADDRESS TEL.# `Residential ❑Commercial Est. •Cost of Construction$ a` Home Improvement Contractor Lic.# _�- Construction Supervisor Lic.# Cj - OS !`0(Q1- Workma9gtompensation Insurance: (check one) if I am the homeowner ❑ I am the sole proprietor ❑ 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 Siding: #of Squares 46 Replacement windows:# Replacement doors: # Roofing: #of Squares. ( /Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing • {�� ' cZ.. , t'lt�.. *The debris will be disposed of at: t. _ �-2 tw3 �.,,,1t ��„,� �{��' `�� (,vi�� Location 4f Facility _V 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. II�t Applicant's Signature: "' 6O Date: / 11 Owners Signature(or attachment) Date: e3 Approved By: _•L,s Date: kb -Lk -`S Building Official(or designee) EMAIL ADDRESS: v COr Y`�+IIV ii ` r%4E."�a1'd ecimirrtt.16.4 r(Am , Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No .� - _—�'— The Commonwealth of Massachusetts -r ';E- = / Department of Industrial Accidents 1— 1 Congress Street, Suite 100 G=_if. Boston, MA 02114-2017 n www.mass.gov/diai , .' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Iictl t'j MO Address: ''%N. 004, c-' City/State/Zip: ftT zo F i'A 6W 3S Phone #: - ~tk--S L(e . 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 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling y capacity. [No workers'comp.insurance required.] 3'llein. I 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. 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct. vitSignature: d Date: 16) 4 i ICI Phone#: —: c 3U- 1. °1i1_ 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#: Division of Professional Licensure Board of Building Regulations and Standards Consf�, t{ {Sp,rvisor :S-06.9667 p ires: 12/11/2020 KEVIN T BAf AT 1 F 31 OAK ST. FOXBORO MA�0t0311,,, Commissioner