The URL can be used to link to this page

Home My WebLink AboutBld-20-003751 - 01,YAR office use only p 4PATtti ' 00 ? / O 1l'r ` . H (Amount 50 1`°"'•�"°'�cad i Permit expires 180 days from l issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146Route28 South Yarmouth, MA 02664 (�,/�� (508) 398-2231 Ext. 1261 �- i-1 CONSTRUCTION ADDRESS: J Po i-•1—(A,f1 - __ Rot . Y/10m a LA-1-1-, "a►qT- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Th!�►��/ 3 C_/Nl Real n .ergo )2y-y9y - €yec7 N,SIVIE✓ PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ +�3, aoo . coo. Home Improovement Contractor Lic.# Construction Supervisor Lic.#� Worl�' \Compensation Insurance: (check one) 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 i]-4 Tent Duration (Fire Retardant Certificate attached?) Wood Stove � \J �t Siding: #of Squares /s Replacement windows:# Replacement doors: # A . s.J`, 'f` Roofinngg: #of Squares ( )Remove existing* (max.2 layers) Insulation �Q.S�/OIdiKfng sH ghway/Historic Dist. (VcReplacing like for like Pool fencing_ *The debris will be disposed of at: I JGCYy\p 5 --C ' S t-3 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 of my license and for prosecution under M.G.L.Ch.268,Section 1. / Applicant's Signature: I 11 /Q.. .4.-41.A,er" Date: o 4, n a(a0 4?..(A../YtL/i.(f Owners Signature(or attachment) o akt (p Date: . 1 c9040 ' Approved By: Date: I ') 4,044 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts r Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 imps www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly 4 Name (Business/Organization/Individual): !1-r y J el)." 1 n` e,i►2Q Address: a£S turf ,r% (Z,c City/State/Zip: 6r noc.c,t-1-, 13 a rcr.' Phone #: 2 24/ riq 4/ - (`l L0 ' Are you an employer?Check the appropriate box: Type of project(required): .❑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 any capacity.[No workers'comp. insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 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 i d 11� 152,§1(4),and we have no employees. [No workers'comp. insurance required.] • DO(, r S *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. Signature: h r� L/VIPf Date: 6 !'1 a()Q 0 Phone#: '7ao `ais- 5 .32 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#: