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Home My WebLink AboutBld-20-003799 - ce Use On '� �YR i 4 --• • • emu 0 O 'i H 'Amount / / 0-6 Permit expires 180 days from i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508){398-22331 Ext. 1261 CONSTRUCTION ADDRESS: 10 U h 5 " W /A 2 /- o TA 7 ft ASSESSOR'S INFORMATION: Map: Parcel: /'OER: A / 1AR A13A .coV c l - C /U ' .2 `I/� gq NAME PRESENT ADDRESS TEL. # Z3 Cn e- /6 >,A,4-TIOAJ CONTRACTOR: N/ S NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est. Cost of Construction$) 7�} Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) XI am the homeowner C I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED — DC1410 Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # 1 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: li5 0 T Le Pi I) 1-1I S T G 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 revocation f m license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 0 //0 3/1 c Owners Signature(or attachment) Date: 0 1/0 9 �.L Cr 1 Approved By: Date: 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: ❑ Yes ❑ No ❑ Yes C No The Commonwealth of Massachusetts t� Department oflndustrialAccidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 me"• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly "Name (Business/Organization/Individual): /7 AlS A G address: b t/ c .6 0-City/State/Zip- v/- t1 8A. Phone #: 6 / - 6 /U - .Z g Are you an employer?Check the appropriate box: Type of project(required): 1.— I am a employer with employees(full and/or part-time).* 7. New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. n 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 E Building addition 4.C 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 S.❑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.i 6.0 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 4 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 un er the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: U t J 0 )2 0 Phone 4: 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#: df / 0911010 ANA- P ' h 6 /4Sav 1 n -e e ci,A9 60 ,ec:z,_e_ ve cv,6 ,i 0 r?/614 ,, ,6. , tcevkt-0-(r_0(7(i.c--0,-/ .. ce-('e-e'c- 1, 4 t1 I J i