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Home My WebLink AboutBld-20-003273 ..y iPermit# / CI 1 ( 119) O/� 1'' . H #3)-773 1Amount /6 K-} q �"° I Permit expires 180 days from - lissuedate J siad EXPRESS BUILDING-FERMI APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Z G to f W\ e t A*L, V ye ASSESSOR'S INFORMATION: `Map: /�/ Parcel: Lilly OWNER: Ili, i.� .!e-,�ti/ co- 6 A SuR - 01 3fi1 NAME PRESENT ADDRESS f, TEL. CONTRACTOR: ICQAt ✓1 �i� f �! C%C i1.lvti\e V K S i�Cc �Z� 7 v Z (EtCa NAME MAILING ADDRESS TEL.# ❑Residential commercial Est.Cost of Construction$ Z 500 () Home Improvement Contractor Lic.# S Ct (, Construction Supervisor Lic.# C'el -.( (, 3 9 Workman's Compensation Insurance: (check one) ❑ I am the homeowner )(I am the sole proprietor ``❑ I have Worker's Compensation Insurance Insurance Company Name: IAA „n C'k • f-Vme�/i`C a yr v 0 Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares '7 Replacement windows: # Replacement doors: # Roofing: #of Squares c ( L4emove existing* (max.2 layers) Insulation �1 �9 Old Kings Highway/Historic Dist. (‘—'('Replacing like for like Pool fencing *The debris will be disposed of at: �rr _ LA. 1 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 or revocati f my license and for prosecutio nder M.G.L.Ch.268,Section 1. Applicant's Signature: .. Date: I<% 1 3 / Z C t ci Owners Signature(or attachment)X V v� g � /� Date: Approved By: L f Date: I � Building Official(or tb E� Zoning District: Historical District: Yes E No Flood Plain Zone: a Yes )2("No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes No ❑ Yes X No .,_\ The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 e ,Ii" Boston, MA 02114-2017 `�� ..5.,s, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 161 J i h \---t. t v.. C 0 N s - 60 Address: 10 c �, c ac ,c ,? a City/State/Zip: po v ii1(A 0 lto-7`5 Phone #: is-c: 3 3 b Ti r(v Are you an employer?Check the appropriate box: Type of project(required): i.❑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. Ell 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.] 4.E I am a homeowner and will be hiring contractors to conduct all work on mYP roPnY� I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑ Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.2s 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.E Other `j(�j�� f `�/`t 1 152,§1(4),and we have no employees. [No workers'comp.insurance required.] V' 6 0 Cl.. l IS *Any applicant that checks box iir`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: T( )y1-a— �,rouj A — M ci n c A- . kvkAAANco C i,i,,,,(-) Policy#or Self-ins. Lic. #: Expiration Date: 611 12 0 7 0 Job Site Address: Cl Z Z A to A \ M e.na kkn l tit 11(4 City/State/Zip: 0 a„,)S Attach a copy of the workers' compensati n policy declaratitn 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 th ains and penalties of perjury that the information provided above is true and correct. Signature: LDate: 1 C /3 I 2 0 t 9 Phone 4: `j C SC 4,Z c.i sz GP 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#: