HomeMy WebLinkAboutBld-20-004697 „~O1.YAR`� Office Use Only
iPermit#
O 'Amount 30
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` MATTACM [SE•�
"e.w,a.„[s E',d i Permit expires 180 days from
0(.14 i i � ,�ue date
EXPRESS BUILDING PERMIT APPLICA ' V !
TOWN OF YARMOUTH , I
Yarmouth Building Department t
1146 Route 28
1 South Yarmouth, MA 02664 , . .1'� RT '
WV (508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: s 6 Cart” W f ( ( 9-"A., �Gtf WtOL
ASSESSOR'S INFORMATION: 1
Map:
Parcel:
OWNER: rJpA CAA. (CAL 3C (.i t 14 L( 5-08---3427'!6
NAIME PRES ADDRESS TEL. #
CONTRACTOR: 1(
NAME MAILING ADDRESS TEL.#
residential ❑Commercial Est. Cost of Construction$ W .V '
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
rI am the homeowner ❑ I am the sole proprietor CI 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 /3 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:
Location of Facility
I declare under penalties of perjury that the st is 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 re i a my cense and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: ' S J., a
Owners Signature(or:�ent) i, Date: Z/L C (2 a
Approved By: jL%� Date: f'". J i
Building Offic or Ignee) E ADDRESS:
Zoning District:
Historical District: ❑ Yes C No Flood Plain Zone: ❑ Yes C No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes ❑ No ❑ Yes T. No
The Commonwealth of Massachusetts
2 Department of Industrial Accidents
1 Congress Street, Suite 100
' Boston, MA 02114-2017
.'
0-,IMP.,.,.- 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): Z-0vv .. (- )Vir
Address: C -}-e,k,,,, /`)/kAki �(36--
City/State/Zip: S. yo., Phone #: SOT `3 47 /cr(5;"Ei-
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 — g
8. _ Remodeling
any capacity.[No workers'comp. insurance required.] —
3. I am a homeowner doing all work myself. 9. ,_ Demolition
y [No workers'comp. insurance required.]t
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.
12.1]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.n Roof repairs
These sub-contractors have employees and have workers'comp. insurance.: C
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other �� u0.�
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.
1.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 cert. er the the pains and penalties of perjury that the information provided above is true and correct.
Signature• .., �' 2 5 —ZC�
Date:
Phone#: nor '147 7rrr
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#: