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Home My WebLink Aboutbld-20-005054 01',YRR i Office Use Only .24 CG.) &Y � l , ,,,,,-1 'Amount MATTACM Esd '`°"°""`, c Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH : Yarmouth Building Department 9 rT - - 1146 Route 28 r �; 1 nl South Yarmouth, MA 02664 `' ` `� (508) 398-2231 Ext. 1261 L,e,1,,,., //,, r ,, i ;,R1, idT Ev >iCONSTRUCTION ADDRESS: I -.iv,on A 6 (1 vw ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 4'V1 p? S ✓�1/ I Z tU via+^ 'v��ye- �j L� G'S �, C j .'3 8. NAME !! PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL./ # Residential ❑Commercial Est. Cost of Construction$ v Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) XI am the homeowner ❑ I am the sole proprietor 0 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 quares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: a"' �'''� 1‘° 1 Sty D 1 o-'F, 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 revo ation of my license and for prosecution under M.G.L.Ch.268,Section 1. 13/202D Applicant's Signature: `_. e Date: Owners Signature(or attachment) Date: 3/1 3/ Approved By: Date: 3- 13 O Building Official(or designee) EMAIL ADDRESS: Kevi�„�i3 rot y 5I4'., w, Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ,E Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No ❑ Yes 0 No The Commonwealth of Massachusetts r 1 r1-' Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 0, .„, 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): 14-&ii i VI G `/ Address: i 2__ M.414vInvi c; _ City/State/Zip t i• N,vybtCvt A Q2' 0(phone #: S ) 2.: ` -0 g Are you an employer?Check th appropriate box: _ Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. _ New construction 2.E.I 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 I am a homeowner doing all work myself. [No workers'comp. insurance required.]' 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. 14.0 Others 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 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 certify under the ins and penalties of perjury that the information provided a ove is true and correct. Signature: ,� -, /3 2020 Date: • Phone#: (5`l 2S <6 - 0t 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#: