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Home My WebLink AboutBld-20-004556 el c Use 1 per. - 'Peril Only c ..eri�� ,. y R? Sb � � �- ' � ,:.Amount r: �ro #Permit expires 180 days from ;�; ... :LIILDINL DEPART fiE issue date By EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 / (508)'398-2231 Ext. 1261 l� CONSTRUCTION ADDRESS: y�16A�( y lv►L) S- - s \I . ASSESSOR'S INFORMATION: Ma ,'M i 104 Parcel(j—)C.) ( W l.� ONER I� I�\ ?� 1 -L�-d.Q' � C r U L foe/ - c- I 9- NAMEE l, 1 PRESENT ADDRESS ��/ �% TEL. # CONTRACTOR: ,'/ /I 11)i all I--e i a-V� /c 2 ��"/,6,—s 4/4 '!8 f if 7 '7J NAME /f MAILING ADDRESS TE # /' YIZesidential ��,JJJJ p Commercial Est.Cost of Construction$ Z( t O Home Improvement Contractor Lic.# a 2� 7// Construction Supervisor Lic.# 0 0 7-yy Workman's Compensation Insurance: (check one) u I am the T homeowner ��❑ I am the sole proprietor S have Worker's Compensation Insurances !�3/v` 9Insurance Company Name: Ll h G /1"'(4 (1 Al ( � �^Worker's Comp.Policy# v 58/CY 7 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares / - ( X )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: RiN Location of Facilit y 1 declare under penalties of perjury that the statements herein contained are true and ct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial or revocation of my lice d for o ution under .G.L. .268,Section 1. l Applicant's Signature: �i Date: d 2 ^/U Owners Signature(or attach ent) -7-d 11 Date: Approved By: 0,- i - ,),0.O Date: �J - 1-��r . Building Official(or des' ee) EMAIL ADDRESS: Zoning District: Historical District: IL Yes No Flood Plain Zone: L_ Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes _! No Li, Yes L No _ . The Commonwealth of Massachusetts le —a/ Department ofIndustrialAccidents r =:/i1- 1 Congress Street,Suite 100 c1— `' Boston, MA 02114-2017 y' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legi r Name (Business/Organization/Individual): /?E ) 0 Cif h(>1--7'Z.,S _0 � Address: /5:2 A/6.,s,4 ,Uf r f v City/State/Zip: Yrmo 1 t1/? 0 2 /phone#: 34W 76f 7-5 Are you an employer?Check the appropriate box: Type of project(required): 1.NI am a employer with I employees(MI 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.] ❑ mode tng 3.❑I am a homeowner doing all work myself[No workers'comp,insurance required.]t 9. ❑Demolition 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 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 area corporation and its officers have exercised their right14.❑Other ❑ of exemption per MGL C. 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /, / Insurance Company Name: /6 e/'7 ktt(/iv /4 7d Policy#or Self-ins.Lic.#: 60(1_7, ,q/ -- ate 97-6 ration Date: /2- 9 ZL) Job Site Address: l? 9 iV 4274-/f- e--fW ,--s 4-_ - City/State/Zip: Ar71( - 402O‘1 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 pains and penalties of perjury that the information provided above is true and correct Signature: L A-g- -r.-- ( / - 4' Date: v / . -Z•0 Phone#: 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#: 111.