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Home My WebLink AboutBld-20-002668 P�4•Y�qR �ei Qt U\ M D CJW Office Use Only V" " . j Permit# S' C' O . y l Amount 2� MATTA n CSC/ ' Cr�3,`�a.<.vta"'e {Permit expires 180 days from l issue date 1 . --a- a(496vc EXPRESS BUILDING PERMIT APPLICATION ' TOWN OF YARMOUTH Yarmouth Building Department ; 1146Route28 South Yarmouth, MA 02664 '., , f .; (508) 398-2231 Ext. 1261 I... _._____...__ CONSTRUCTION ADDRESS: 5 ( JV Ck1'(Yl Acutt. C�'�O k k. ASSESSOR'S INFORMATION: Map:V -Vet Parcel: l OWNER: t�k. I� 5�I �'C A_� AWL s%. -VO4-1�0'�9I S63-2.�y 1436 NAME I PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est. Cost of Construction$ 318'b o ' Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) $I am the homeowner ❑ I am the sole proprietor J 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 Replacement windows: # Replacement doors: # Roofing: #of Squares ) 8 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 40..,e...4, 1__.-- Otis et5 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 revocation \ofmy license and /for prosecution under M.G.L.Ch.268,Section 1. j Applicant's Signature' t V vim— JQ Date: I I -7—l q Owners Signature(or attachment) A tK ' ' Date: Approved By: '-‘ Date: 7 ' 7 Building•'-ci. or d-signee) E ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: a Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes No r The Commonwealth of Massachusetts .` I *a l Department of Industrial Accidents _� MIMMN ►el- 1 Congress Street, Suite 100�= Boston, MA 02114-2017 a,M 5�.v _ www.mass.gov/dia \orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): V . 1 t —1-61 l ( 4_6611 Address: S t S J r ,4-144J City/State/Zip: S `"\o1.Cyand-L_ Phone #: cO&--1 ,O 1632 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. 0 Remodeling any capacity. [No workers'comp.insurance required.] 9. ❑ Demolition 3.K..I am a homeowner doing all work myself. [No workers'comp. insurance required.]t l0 ❑ Building addition 4.0 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. 12.0 Plumbing repairs or additions .i.❑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. 4: 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. f-Signature: )4" Date: / (-- 7 17 Phone 4: O$—1(0 O --163 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 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#: