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Home My WebLink AboutBld-20-004791 01'.1(lit a Office Use Only iPermit# Ou. Il H !Amount o CSE *`°"°""0 4 d 1 Permit expires 180 days from {issue date B Lt)-a0-97QI 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: