HomeMy WebLinkAboutbld-20-003866 :O4;YRR ?Office Use Only
`r C F. 1 9 E. D Permit#
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_ ,-........ c,d,' JAN 13 2020 ;Permit expires 180 days from
_ :=:••'' 0.) i issue date
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j CYEXPRESS B APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 •
CONSTRUCTION ADDRESS: -z/9 (G{ 5 i �/ S ✓y
ASSESSOR'S INFORMATION:
Map: Parcel:
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OWNER: i -0._ie Se1)1/1 a E K qg e� 7; S`je ii/ /-508-�'%o-b? ,
NAME PRESENT ADDESS TEL. #
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CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial Est. Cost of Construction$ ,(a,M
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Wor an's Compensation Insurance: (check one)
the homeowner 0 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
i
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Siding: #((Square , Replacement windows: # Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
Ahe debris will be disposed of at: II-t (4j rC'f'—
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: Date:
Owners Signature(or attachment) \\` �(j - /Date:
//
Approved By: G Date: f ti,26
Building 0 ial(or gnee) EMAIL ADD S:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 2 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 2 No ❑ Yes 2 No
The Commonwealth of Massachusetts
1_"? Department of Industrial Accidents
j 1 Congress Street, Suite 100
Boston, MA 02114-2017
o, .,- www.mass ovv/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): e S&d U pa w
Address: °fj/? ((o fl 5 /,4
City/State/Zip: $c' Phone #: fo 3- 927- AJ,35
Are you an employer?Check the approp iate box: Type of project(required):
1. I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.E I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity. [No workers'comp.insurance required.]
9. [ Demolition
3.21fI am a homeowner doing all work myself. [No workers'comp. insurance required.]t
10 E Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
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
6. 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.i
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. ir: 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 he certify under the pains and penalties of perjury that the information provided above is tru and correct.
Signature: Date: 10.'"
Phone#:
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#: