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Home My WebLink Aboutbld-20-006274 d �Y9 6 ..• � ! wtit r t •R C Office Use Only ' O ; r Permit# o �� y: S P JUN 17 2020 i 50/ i .: Amount y G ` K T =N i .Per mot expires 180 days from _' _ �-_�_ issuedate EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH , '` '20 J b Z7 T Yarmouth Building Department l 1/ 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 138 Quartermaster row,$.Yarmouth ASSESSOR'S INFORMATION: Map: Parcel: OWNER: lone segues 138 luartrmaster rew 5083811520 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# IResidential 0 Commercial Est.Cost of Construction$ 612 'vD Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) II am 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 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: ■ mint!town dump 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 I Applicant's Signature: Date: /�Q Owners Signature(or attachment) 8/1V/20 Date: Approved By: Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: r0 Yes Li No Flood Plain Zone: [ Yes L No Water Resource Protection District: Within 100 ft.of Wetlands: Yes [3 No U. Yes ❑ No The Commonwealth of Massachusetts Department of IndustrialAccidents =/�l l Congress Street,Suite 100 Boston,MA 02114-2017 •Y`'.r; ` www.mass.gov/dia \Yorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTIN( AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Nene Rell®eS Address: 138 eamennester row City/State/Zip: :M.Minna Phone#: 5083611520 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in VEZ1 Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself o workers co t 9. ❑Demolition[N mp_insurance required.] 4.0 I am a homeowner and will be hiring contractors to my property. I will all work on10 D Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs 6.0 We are a corporation and its officers have exercised their 14.(3 Other 152,§I(4),and we have noright of exemption per MCsL c. 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.#: 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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: }1eiioRdritl&s Date: 6/12/20 Phone#: Official use only. Do not write in this area,to be completed by city or town offuaL 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#: