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*`°"°""`°"9 c Permit expires 180 days from
l issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: L16)- rota,, fe,c ,l Wa-Sir 1�(
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ASSESSOR'S INFORMATION:
Map: Parcel: ¢� Z
OWNER: J 9C.S' \ 1"t(9 S L LC_ 5 78 - J 7 J- �t0�.
NAME RESENT ADDRESS:t TEL. # 2 ^�
CONTRACTOR ll+(&I' (c.+5 0 7.0- � 4 7 5�c.v'- c ?l '1 5-636/- C)?p
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NAME MAILING ADDRESS ► ) i us-6
a- TEL.#
0 Residential Lf Commercial Est.Cost of Construction$ i j S 00 0
Home Improvement Contractor Lic.}_ I
° I'b Construction Supervisor Lic.# GS— to 435 S 7
Workman's Compensation Insurance: (check one) `
❑ I am the homeowner 0 I am the sole proprietor I(I have Worker's Compensation Insurance
Insurance Company Name: "-rile- ilart4rd Worker's Comp.Policy# 01/LECC-LA u 6l(
• WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows: # Replacement doors: # L1�
Roofing: #of Squares ( )Remove existing* (max.2 layers) ,__--insalatien...__,_
R
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing -` ____1 i
,
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*The debris will be disposed of at: ()as k
Location o Facility `7 V
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and 1)44.---1 rdersrali'd ttI dts'�aPfSGve 3t I
3i1�Yr(s)
will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. 9
Applicant's Signature: /Date: / 7 /)6
Owners Signature(or attachment) Date: / /c72vtt?.
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Approved By: ( if/2_41,,a,wri....e_____
Date: — la — �.0
Building Official(or design EMAIL ADDRESS: t ' ` �'NIt Ci r �, we5L0'6(rl�rl-�
r in
Zoning District:
Historical District: 0 Yes E No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes E No
` The Commonwealth of Massachusetts
r Department of Industrial Accidents
1 Congress Street, Suite 100
/2;3 Boston, MA 02114-2017
��� �•`'� www.mass.gov/dia
m.
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): / �,w. . to./ S
Address: P_ d„ X3-7
City/State/Zip: )cts� ,�_.. II1\ Phone #: CO 6 3C57 0
Are you an employer?Check the appropriate box:
Type of project(required):
am a employer with 6 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. I am a homeowner all work myself. 9. ❑ Demolition
❑ doingy [No workers'comp. insurance required.]t
4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. 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.E Plumbing repairs or additions
5.❑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.❑Other
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.
r 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: L— thr4 GreA
Policy*or Self-ins. Lic. #: 09T (� Expiration Date: in/01
Job Site Address: 1t9. Mita. 9(feek -)0 e* �G( City/State/Zip: rn4 so A6-73
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.
Signatur . Date:
Phone 4: B egg -7c9
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#: