bld-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#: