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Home My WebLink AboutBld-20-003581 ;YR Utttce Use Only o R • Permit ` ' l C: ,o . _ .s.H !Amount ` MATTAGM £S[ ' 'I 4,-.44 �00,::::a!,/ J 1 Permit expires 180 days from eb 0 ;issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department , 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 / CONSTRUCTION ADDRESS: C,m A ` , 1� r Qti R4., , �. Q f; at� (1-1 i/ ASSESSOR'S INFORMATION: Map: Parcel: 5 Q / OWNER: J.. % h P -i""' k-Y),-q. .�,•p y1 1� r ( 9 A t) 0 " —) I u—� 1 2 1 1/N ) `� Y\cis.IGO NT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# 1.7 Vesidential ❑Commercial Est. Cost of Construction$ ' f c 2 oo Home Improvement Contractor Lic.#\ 0.A4L, p^I U Construction Supervisor Lic.# Workm 's Compensation Insurance: (check one) PI 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 1 0 Replacement windows: # Replacement doors: # v 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: 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. 'Owners Signature: Date: /Owners Signature(or attachment) Date: \ , ✓✓✓ Approved By: *�,. Date: k l — C!d, .3"'1c1 Building Official(or desi ee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: E Yes n No Water Resource Protection District: Within 100 ft. of Wetlands: Yes ❑ No ❑ Yes 2 No The Commonwealth of Massachusetts ►` Department oflndustrialAccidents 1 Congress Street, Suite 100 `, Boston, MA 02114-2017 °�...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): I q,/ON; y�� (��j � �Y Address: (� $, t V- `'� City/State/Zip:�tiY�Y'' yv\t3 o'\\ id Phone #: o��'3� ys Are you an employer?Check the appropriate box: Type of project(required): l. 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. E Remodeling any capacity.[No workers'comp. insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp. insurance required.] 10 E Building addition 4.�m 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.E Plumbing repairs or additions 5.❑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. 14.7 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. #: 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:W YLI;,.. Date: (/ Phone;T: 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#: