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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
,n` ,CONSTRUCTION ADDRESS: p�� A ttdd FteitS vannoUt 11 ()UM
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: 140 O'Ml(\ N ISS►IC) Ko1k Mit.''aIto-18(0fl
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Residential 0 Commercial Est. Cost of Construction$ `\ 31X)
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
fI am the homeowner ❑ 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 Z.\ 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 atX y ) 1 M 11 1
` 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: (' q Date: 016 cl 9D
:::::::thh1
Date:
Buil 5 0 (or esibee) Ei DRESS:
Zoning District:
Historical District: ❑ Yes No Flood Plain Zone: ❑ Yes E No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes 0 No ❑ Yes 0 No
The Commonwealth of Massachusetts
1� 2 Department oflndustrialAccidents
1 Congress Street, Suite 100
U Boston, MA 02114-2017
•.,M�s�•`''� www.mass.gov/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): t OCALch 1 ' wt V,
` j Address: a Q tik.ad&\ F\-arj 'EWe,
'Ce City/State/Zip: 'toe,* lognoutf m1tab$ Phone #:11y QL.1.C1)—t6-(0-1
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. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. ❑ Demolition
10 ❑ 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.:
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 R1 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 4 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 certifypy� under the pains and penalties of perjury that the information provided above is true and correct.
Signature: I�-u1JC Date:
Phone 4:
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#: