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Home My WebLink Aboutbld-20-4585 vuicc use vmy -AO' -.AP 4) Lt. WS 0 Amount `Hr .{ 7 ` MATTA M cst C**Patt C d` -:i Permit expires 180 days from 1 issue date EXPRESS BUILDING PERMIT APPLICATICil -E -- TOWN OF YARMOUTH $ Yarmouth Building Department 9 ' -- �!�`� 1146 Route 28 � ` ` i j rrpARfet ! South Yarmouth, MA 02664 ; (508) 398-2231 Ext. 1261 y� n CONSTRUCTION ADDRESS: 1 CAP/A IN . INt'M-�N-- ,z S` y'71`Iti ocT H ASSESSOR'S INFORMATION: Map: CAP-Mitt Parcel: OWNER: l)4V RC` ODD--S it/ I5LMM�I�-S Ri).. 5bS--) O- L Li 2_ NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ ovo` t Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) y1 I am the homeowner ❑ I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: r4/ /3 v Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares lb Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (>0 Replacing like for like Pool fencing *The debris will be disposed of at: T2AN5/ -L 5 rt} T/U N 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 revocation of my license and for prosecution under/ M.G.L.Ch.268,Section 1. Applicant's Signature: t�U_d.+j r`n`�Y Date: 2_AO/2 45 Owners Signature(or attach i, t) /24147 Date: 2_ r 2_0//7 �) Approved By: 1 -. Date: (7Y19› 02 d ding Official(or designee) EMAIL ADDRESS: /2/ -VL—iu'tclic; <jS) 6-it-iiIi c-, COM Zoning District: Historical District: 0 Yes x No Flood Plain Zone: 0 Yes f No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes / No ❑ Yes Zl No • '� The Commonwealth of Massachusetts 1 L Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 42114-2017 -14,,�5�•'•y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): D A V(n -RH 0 D,-S Address: // }PT/-I- ,'J ,jimitAoN-S , City/State/Zip:_ S; YA,Z-Mou77-1 02h6Y Phone4: 5o4-3-o-2 -2_ j 2- 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 XI 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 m YProPenY• I will 10 Building addition 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.❑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. iContractors 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. #: 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: ,p z,��alu� rr Date: Phone*: ‘7 O — 3 8-o '- >_ ' �_ 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#: