HomeMy WebLinkAboutBld-20-3641 Office Use Only
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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: C �"�A/Ki 7, yoz.14,korb-ii...1t 2-T, L/2L -5
ASSESSOR'S INFORMATION:
Map: / 2- / Parcel: 'L 7�
OWNER: ��N(4) A:0i4'C A.5G� 1/k)j1 a& 7j jOi-X47J� 7dJ7
/
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: 54-77//de
NAME MAILING ADDRESS TEL.#
1'11.esidential 0 Commercial Est.Cost of Construction$ �� C)
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Wo an's Compensation Insurance: (check one)
I am the homeowner 0 1 am the sole proprietor 0 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 V Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
x Old Kings Highway/Historic Dist. Replacing like for like /C.41/1-r Pool fencing
*The debris will be disposed of at: A ekkte5-&72_ r ( -47 j 71cr."/
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: Date:
Owners Signature(or attachment) Date: l Z�C) l P {
Approved By: Date: `` /j. ✓
Bui g O ial(o designee) E ADDRESS: xi/e. eyed,// 61,(..„
Zoning District:
Historical District: 7 Yes L No Flood Plain Zone: ❑ Yes E No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes 0 No Ll Yes C No
The Commonwealth of Massachusetts
x=�
�, i=A/ Department of Industrial Accidents
_:4t1_ a 1 Congress Street,Suite 100
1*_ Boston, MA 02114-2017
„ www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information p Please Print Legibly
Name (Business/Organization/Individual): jd/� TM) �, �2
Address: l
City/State/Zip: �c jZ��TC,_pGC21 Phone#: e� "�e� 7
Are you an employer?Circe the appropriate box: Type of project(required):
L❑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. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
93�, am a homeowner doing all work myself[No workers'comp.insurance required.]t 1 ❑Demolition
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
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.:
13.❑Roof repairs
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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and j job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date: }�
Job Site Address: 4. RAJ L) 57% City/State/Zip: lLIZ1t.(ti(a r/t l' 7 0
Attach a copy of the workers'compensation policy declaration page(showing the policy ber 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. e
I do hereby certi u the p ' pe es of p ' at the information provided above is ue and correct
Signature: Date: /2--7
Phone#:
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#: