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EXPRESS BUILDING PERMIT APPLIC�. _
TOWN OF YARMOUTH 1 r-- ----- -
Yarmouth Building Department i
1146 Route 28 1
South Yarmouth, MA 02664 I _. , "I
BI:I� arr�i�:�,
(508) 398-2231 Ext. 1261 1 By
CONSTRUCTION ADDRESS: q 111"-- ry r 3
ASSESSOR'S INFORMATION:
�y,,,(` -- Z Map: Parcel:
OWNER: Sevl D1/(/'r`r�t a t/ /3 (.i-e rGi/k<
NAME PRESENT ADDRESS TEL. # G C�
CONTRACTOR: 3 '� Q A%(o a(s y
NAME MAILING ADDRESS TEL.#
sidential ❑Commercial Est. Cost of Construction$ i. 000
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: # I
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: 12L44 C/ tom- C. art.,/'
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: 2 Pi/Z-0 ZU
Owners Signature(or attachment) Date: Z(If(--2 - 7—e)
Approved By: Date: 2 /f�Q
Buil . g ial(o designee) MAIL ADDRESS:
Zoning District:
Historical District: 'E Yes C No Flood Plain Zone: 0 Yes 11 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 2 No
The Commonwealth of Massachusetts
e 1 ir Department of Industrial Accidents
I 1 Congress Street, Suite 100
Boston, MA 02114-2017
imp .•`''< 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): 5' fit 18 izoce. %a,, s-y
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
[am a employer with employees(full and/or part-time).* 7. E 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.k.am a homeowner doing all work myself [No workers'comp. insurance required.]t
l0 ❑ 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.E Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.E1 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
14. Other S. Ic -'4
a
6. We are a corporation and its officers have exercised their riaht of exemption per MGL c.
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.
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 r or Self-ins. Lic. n: 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: Date: Z7/l/Za Zp
Phone 4:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License 4'
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#: