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Home My WebLink Aboutbld-20-004494 v Fi unice use unly 01' Y ARC rm410 c24 10 L1 O . _ ' . H !Amount u ` MATTA M ESE ``""°'�'t, cad Permit expires 180 days from -` issue date EXPRESS BUILDING PERMIT APPLICATI .�� "___.. r ECEIN Eb TOWN OF YARMOUTH ! r..._ A /1 Yarmouth Building Department 1 t 1146 Route 28 1 . Fb 14 M A t South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 i ILARTMENT 3Y CONSTRUCTION ADDRESS: 0(— ASSESSOR'S INFORMATION: Map: Q Parcel: OWNER: % /) !/t oQp E / k - J✓ a5- 9Sc'-ME < / PRESENT ADD SS j"/ „_4. _ TEL. # CONTRACTOR: Q � J r NAME MAILING ADDRESS TEL.# / C�Residential ❑Commercial Est.Cost of Construction$ Sc>b Home Improvement Contractor Lic.# - _ Construction Supervisor Lic.# WorkAI 's Compensation Insurance: (check one) am the homeowner ❑ I am the sole proprietor 2 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 ..44_ Replacement windows: # Replacement doors: # 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: �J / Location of Facili 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 rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: vL i�,tti --e— Date: ,=.2 - / z!1 Z O Owners Signature(or attachment) �p1 Date: — /`f — ,.Ze 2 [) Approved By: eK, `/ Date: �`/� Building ffici or igne Ei DRESS: /Q6i or�G /®? ra / DL 2 Oz_1)• C ail) Zoning District: Historical District: D. Yes i No Flood Plain Zone: Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes _ No , • 1 4 The Commonwealth of Massachusetts Department of Industrial Accidents �, a IT 1 Congress Street, Suite 100 ..--,.. e ,....„ Boston, MA 02114-2017 .1*1/4,.. -lit ,mp 5-•`'y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeFibiy Name (Business/Organization/Individual): / 1ep& Address: / , ,! G'PEtii)e-iavc_E' ,4, c44 3 City/State/Zip: la fr mi2tl 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.❑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. am a homeowner doing all work myself. t 9. ❑ Demolition y [No workers'comp. insurance required.] 4.❑ myProPenY�I am a homeowner and will be hiring contractors to conduct all work on I will 10 ❑ Building addition 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 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.= 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. I4.❑Other S°/� „Li 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. 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 DLA for insurance coverage verification. I do hereby ce ' under the ins and penalties of perjury that the information provided above is true and correct. -41w Signature: Date: 2//Vj2C7 Phone#: S) 2egro q/ 7 6 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#: