Bld-20-004791 01'.1(lit a Office Use Only
iPermit#
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*`°"°""0 4 d 1 Permit expires 180 days from
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department ! s
1146 Route 28 I -=
South Yarmouth, MA 02664 ':
508 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: ` ` SirekotA, /tv e
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: p\/�fi{ Va.A L.a,rQ, 79 64fibs 4 S O 39k- LI'7 (�
PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
'Residential i]Commercial Est. Cost of Construction$ 15 d6
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workm 's Compensation Insurance: (check one)
It 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
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares cg, Replacement windows: # Replacement doors: #
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: '/1lfly1 G(i4 -N O.4
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 revocation14 ofa my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: �J' 44,1f_ Date: 3-2, ZO
Owners Signature(or attachment) V Date: 3'
Approved By: .^�.�L Date: — ONO
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes No Flood Plain Zone: Yes 11 No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes 0 No ❑ Yes _ No
•
The Commonwealth of Massachusetts
>r Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
,m r• www.mass.go v/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information j�" Please Print Legibly
J
Name (Business/Oraanization/Individual): PA illI7 Yin A-cc
Address: I q (514,110n. AVe
City/State/Zip: $, u #4/4 0 Zb 6 y Phone #: 5—of 3? - Y�q�
.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.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp. insurance required.] —
3. 1�I am a homeowner doing all work myself. 9. ❑ Demolition
y [No workers'comp. insurance required.]`
4. I am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 ❑ Building addition
— P property.
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.El 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 4 or Self-ins. Lic. ;r: 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: Date: 3- 2---
Phone 4: ,SOk 3ft-- YfiL
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 TM: