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Home My WebLink AboutBld-20-004611 �►1q ;Y • ffice Use Only 0 AR•�• erm —al(� d S`6 0 tl' C �6 O '�+1�"- H- Amount 4""0 "0 '3 cam ` Permit expires 180 days from issue date t ECEIVED I RESS BUILDING PERMIT APPLICATION E� � 1 TOWN OF YARMOUTH -J Yarmouth Building Department a.;irtgeD-DEPaRT 1 1146 Route 28 I.1_._ --- South Yarmouth, MA 02664 r (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: / S Cct� 101Girit C4XSe r! Sr l ctcnc lUk 1 /" `'f4 ASSESSOR'S INFORMATION: // j I Map: "A Parcel: , OWNER: gcl 11 (—Li IS Ccip"AIA 6tac e r1 S, Kcpt .�ill `l7V- 337- , NAM PRESEW ADDRESS TEL. # CONTRACTOR: TDM 11 .te 7 C s vc i I (`,J t�ctci ,(�5, , h 7 7V SA 1 O0`l.s s/ L NAME cJ MAILING ADDRESS TEL.# �,�,, Residential ❑Commercial Est.Cost of Construction$ �v o` Home Improvement Contractor Lic.# L R A 53 Construction Supervisor Lic.# CS —/0 72 S3 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:# c- Replacement doors: # ca. 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: r T S'� � aM�� I°�!l (.� 41�A 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 revocat' i of my li ense and for prosecution under M.G.L.Ch.268,Section 1. 11 Applicant's Signature: Date: d /I jot°40 cl;______ Owners Signature(or attachment) Date (P/(3/ 2a,Za Approved By: Date: -/2 o Building ci d ignee) ERESS: Zoning District: Historical District: 1 Yes -- No Flood Plain Zone: ` Yes G No Water Resource Protection District: Within 100 ft.of Wetlands: Li Yes No I Yes 1 No The Commonwealth of Massachusetts _7-- Pi!= =y Department of IndustrialAccidents ap=. 1 Congress Street,Suite 100 • rs?,= Boston, MA 02114-2017 ti www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. AnDlicant Information Please Print Legibly Name (Business/Organization/Individual): 1 (7 A ("lc u.e Address: 7 CATtle H/C / (' S, City/State/Zip: S. Ytimo-Akt, /'-lk ( U-4 Phone#: Sd-'l O 0 615 Are you an employer?Check the appropriate box: Type of project(required): i.❑I am a employer with employees(full and/or part-time).* 7. 0 New construction 3 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 doingall work 9. ❑Demolition ❑ myself[No workers'comp.insurance required]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will I0 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole MO 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 These sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. tContractors 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 ' and penalties of perjury that the information provided above is�true and correct Signature: Oropy/ Date: oL /1/oeUp10 Phone#: `Z7, g f o o4“. Official use only. Do not write in this area,to be completed by diy 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#: