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Home My WebLink AboutBld-20-004292 ,hgR ;umce use only Permit# (OIL - H l Amount L v •'-` MATTA N CSE *..,0•41[0."c�d�' Permit expires 180 days from (� ,�ssue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 ... South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 `l '' 21126 CONSTRUCTION ADDRESS: m ASSESSOR'S INFORMATION: Map: �, Parcel: OWNER: C� ii�i /9 �(G.r✓J � ' $2 V 373 r0. ' NAME C `'SENT ADDRES, TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential ❑Commercial Est. Cost of Construction$ L do 0 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman'ss Compensation Insurance: (check one) 1 am the homeowner ❑ I am the sole proprietor 2. 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 Rep cement windows: # Replacement doors: # Roofing: #of Squares 2D ( Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: /43/6" ,,,e '3i 4// ocation of Facility I declare under penalties of perju at the stateme is rein 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 r ..atio f n and for prosecution under M.G.L.Ch.268,Section 1.Applicant's Signature: /ady Date: : ///Zp Owners Signature(or atta hment) ^ v Date: _ Approved By: i Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes No Flood Plain Zone: 12 Yes -,, No Water Resource Protection District: Within 100 ft.of Wetlands: Yes ❑ No ❑ Yes I No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 M s.•' 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): 5eCek7 ‘Ve,• Address: /d �,c, 15r T City/State/Zip: faiji-tau* Phone #: 56% 373 zio 9 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. C New construction 2.—I am a sole proprietor or partnership and have no employees working for me in g 8. — Remodelin any capacity. [No workers'comp. insurance required.] — 3. I am a homeowner doing all work myself 9. C Demolition y [No workers'comp. insurance required.]I. 4.❑ Y I am a homeowner and will be hiring contractors to conduct all work on m property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.C Electrical repairs or additions proprietors with no employees. 12.0 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.�e Other new � 152,1 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. 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-contactors 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 u; a er the pains nd nalties of perjury that the information provided above is tr e and correct. Signature: Date: 2/7/ 20 Phone;: 6-6g 3�3 o'9 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 m: February 3, 2020 To Whom It May Concern, I am applying for a permit to improve the roof on my house located at 10 Captain Bragg Rd.in South Yarmouth. This home will be my primary residence shortly as I am approaching my retirement. Sincerely, Se Mca