HomeMy WebLinkAboutBlld-20-003973 /0 AR 1Urtice Use Only
! O, ;Permit*
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•:=�;�:....• ,�� "' ZV��7� ;issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 C 0 lq 1,0(.0
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: I_ 5- O('q G f` 5-7 , y f O/,'r
ASSESSOR'S INFORMATION:
Map: Parcel: �/)
O WNERtJ C� `I el 4- 5-T9 4 et tit H c.v./ de_ l J" g " 73 7 - I Z I a
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: c Q- / tC.
NAME MAILING ADDRESS TEL.#
61, a Residential 0 Commercial Est.Cost of Construction$ �,o
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
)(1.!!am the homeowner E I am the sole proprietor E 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 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: 0 e-lifO 5 'l e e T go Lk S pc, ,.Li ct T v:a' # 4 I z d I-e e4 Se' '
/ Location of Facility S.
declare under penalties of perjury that ements herein contained aze true and correct to the best of my knowledge and belief. I understand that any false answers)
will be just cause for denial or revoc. l my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date:cJ G i ) 7 Z O Z O
Owners Signature(or attachm• t) Date:
Approved By: 0./ Date: 1 ^ 7 — 4-ci
Buil." g Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes E No Flood Plain Zone: E Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes ❑ No E Yes _ No
1
The Commonwealth of Massachusetts
' ' L Department oflndustrialAccidents
l; 1 Congress Street, Suite 100
Boston, MA 02114-2017
NMI5r•`''y www.mass.go v/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): v C: tu,k_ -I-- c3— 2C-, ILLct-t de
Address: 2, 5" 9ea Ice s' 7-
City/State/Zip: i/ct e.10 Ge 77 /..� o r`r Phone #: g 7? 7 i Z 1 0
Are you an employer?Check 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.] —
3.1I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on mYProPrtY e I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 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.❑ROOF repairs
These sub-contractors have employees and have workers'comp. insurance.
6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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=or Self-ins. Lic. m: 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 imprisonme /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. • ,py of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi der the pains and penalties of perjury that the information provided above is true and correct.
/
Signature: 1 Date: c.� LA J `j 'Z d 'Z o
Phone4: re,g -73 7 1 —i_l c.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License 4
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 4: