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Home My WebLink AboutBld-20-003446 �Y (i vuUCC use vniy 4 . . Permit/4 4 i--- 0 . y i Amount (/ 1` MATTA A CSf "`",e.ac.o^� d,r 1 Permit expires 180 days from •:__*;:.. i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH .- Yarmouth Building Department 1146 Route 28 � ^�`� South Yarmouth, MA 02664 (C / (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3ci -uo c PD .Si v /(.dh,d-1 ASSESSOR'S INFORMATION: r +Map: Parcel: OWNER: E_itti e. 1-7`6"EUu V7 P1 Z-1 I.," ‘Xf)y 1.7, NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ 41-/,0t fie,Otl Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietor D 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 42,40 St ( emove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: YA,2$41(],1 d illL� ocation ofty 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 attachm vt, Date: /2 - /- /I' Approved By: 7 Date: /2 /2�7 Building Official(or de ',,ne EMAIL ADD S: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 01 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 0 No 1 The Commonwealth of Massachusetts 1 i� , Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,�,5.„-> www.mass aov/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): , /---Ept/ Address: - / 9 Ami City/State/Zip: A/y /i344 Phone #: y'4 - 6s. ,g Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. E 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. I am meowner doing all work myself. 9. ❑ Demolition y [No workers'comp. insurance required.]` 10 ❑ Building addition 4. 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.❑Plu ing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oo airs These sub-contractors have employees and have workers'comp. insurance.1gov - 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ther 152,§1(4),and we have no employees. [No workers'comp. insurance required.] i *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. rr: 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 pain and penalties of perjury that the information provided above is true and correct. Signatur : Date: 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 4: December 16 201 To whom this may concern, I plan in the near future to move back in to my residence at,344forest mad so Yarmouth MA 02644_This will become my permanent residence. Thank raw lkir your lime,. Mine