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Home My WebLink Aboutbld-20-004384 ?Office Use Only r,,- pU . 1 . y i Amount ` MATTA n CS[ 4r _1 _ `t-0"...n.^9:,;d,. ;Permit expires 180 days from !issue date EXPRESS BUILDING PERMIT APPLICAI , " TOWN OF YARMOUTH a 7._ --x Yarmouth Building Department z c .. ,,), 1146 Route 28 South Yarmouth, MA 02664 ', u,rv- ' ;EPA r-n (508) 398-2231 Ext. 1261 _ -- s CONSTRUCTION ADDRESS: 12. poll. �R (�E J0"iv I H, 71 M4 02 . y / ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 5L)SAr+ H-F.RA:4co 92PHy&c(4 OE $ir)4 r it/neon, A.0 e' .y SOX-39y-BSE7 NAME PRESENT ADD) SS / TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est. Cost of Construction$ 40'&70-O C'1) Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) X I 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 Replacement windows: # I �o sL.,DiR' Replacement doors: # r 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: i,rpl y AA/ho v-rho- 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 and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: f//�� 1%/, /!� -.E—f, Date: r �/ Owners Signature(or attachment) 7y LEI1--4-4, Date: Approved By: '7 Date: �� Building 0 i r desi5 ee) E DRESS: Zoning District: Historical District: ❑ Yes No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: Ti Yes ❑ No 0 Yes No The Commonwealth of Massachusetts 1:', Department oflndustrialAccidents 1 Congress Street, Suite 100 ' ii: Boston, MA 02114-2017 5.• www.mass.gov/dia IMP Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 51)5,44 N. Fro Ncv Address: '1 2- P 14 y Lc-I s De . City/State/Zip: S , V,4Q/„ci,.774 MA 0?44 y Phone #: 5-41-3 iy- 8 sG 1 Are you an employer?Check the appropriate box: Type of project(required): I.E1 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.] 9. Demolition_ 10 Building addition 4.E 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.E 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-41 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: . Date: vi...&/r.sd...AL_ Phone#: ,Sp2'-(,Z4t/ -a390 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. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: