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Home My WebLink AboutBld-20-004640 Office Use Only o rM��.'� y: 1 `�-OU 7 Amount raft rr , 9 !!�' cc�-1 ' "i �E1) 1 ftTN+f I Permit expires 180 days from issue date i I,0ki;(\ / i EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �, f (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: X I I Q o w> it_b CG-7-70G (f ASSESSOR'S INFORMATION: Map: SO Parcel: /-Y. i OWNER: Jeffrey Mello 21 Wood Rd 7743538044 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# RResidential 0 Commercial Est.Cost of Construction$ 3000 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm 's Compensation Insurance: (check one) I am the homeowner ❑ I am the sole proprietorsTr C 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 2 Replacement windows:# Replacement doors: # Roofing: #of Squares 8 ( )0 Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Yarmouth dump 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 licen and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 2-21-20 Owners Signature r a ment 7 V/r Date: 2-21-20 Approved By: Date: ,2-y0 Building Offici (or ignee) MAIL ADDRESS: r2 Zoning District: Historical District: Cl Yes No Flood Plain Zone: Yes I No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes ._. No The Commonwealth of Massachusetts _ l Department oflndustrialAccidents • _�1_ y 1 Congress Street, Suite 100 Boston, MA 02114-2017 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): Jeffrey Mello Address: 19 &21 Wood Rd City/State/Zip: South Yarmouth, MA 02664 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 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 0 Building addition 4.0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other Roof and siding 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 pai and penalties of perjury that the information provided above is true and correct Sienatur Date: 2/21/2020 Phone 77 5 8044 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#: