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4`°""•"' cTd jPermit expires 180 days from
{issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231--7 Ext. 1261
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CONSTRUCTION ADDRESS: 56 7 U iick Si6Ad Ieaij. t/af✓no>J'ik 01 f, 0 Z 7.3
ASSESSOR'S INFORMATION: Si' 4 II rEt)4 sI
n e4 - ✓Jt U I 1 ` T>I
Map: Parcel:
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OWNER: 1 i,1 cr, 'ar m0vR
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: 61/43 5•c,. / nt�ti b+l .5�. C. i +, 0144,oZ/U 1-6 1 7-567-bacz)
NAME MAILIN ADDRESS TEL.#
❑Residential Commercial Est.Cost of Construction$ 3 5 ( /01<
Home Improvement Contractor Lic.# Construction Supervisor Lic.# C S - III 2 F3
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor d I have Worker's Compensation Insurance
Insurance Company Name: A(ra.,) 4U14.4I 141,iuraps[t aired y. Worker's Comp.Policy# - 74"" /9ZN49 ,
WORK TO BE PERFORMED }(�, D�/ �jll)
Tent Duration GOS4 y S (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 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: SafAc L;r, _ iresits+rt./ &Wt ov'1 ¶00 MA - 1,3 D C•Savtliwit tx M/ , 62 53 7
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 revocc iioo of my license and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature• f i Date: /— I OW
..9
Owners Signa a(or atta meat) ) Date: I 7 "Z-Z)
Approved By: Date: / '.' Z o 2 e,
Building Offici r EMAIL ADDRESS:
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Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
The Commonwealth of Massachusetts
• IP_'151 a I Department of Industrial Accidents
-ER= 1 Congress Street, Suite 100
.64 04
_.-4 Boston, MA 02114-2017
�.�. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 6'V IA) T>)C.
Address: /7'6) ee onA-7I la' f?oJ v�r� , OZ 11 F
City/State/Zip: f 4at ign `/4, 07/7 k Phone #: /- 6/7- S6 7 - 6 00()
Are you an employer?Check the appropriate box: Type of project(required):
I.®I am a employer with 7.5 employees(full and/or part-time).*
7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp. insurance required.] •
3.❑I am a homeowner doing all work myself.[No workers'comp. insurance required.]:
9. Demolition
10 0 Building addition
4.0 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.❑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.*
6.0 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.
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: /4f,L4, v,/4,ce / ii P41,1 y
Policy#or Self-ins. Lic. #: -44 74- /9ZL// Expiration Date: //1/ ZO Z I
Job Site Address: SD 7 &ue h. IS X J City/State/Zip: it). I41'nait 11414,o Z.g 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.
Signature: y : Date: / 7 2O Z!)
Phone#: /-4/0 - 71/7 • 0'117
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#:
S►�g11 �� �� 5k I
o YAR TOWN OF YARMOUTH
BUILDING DEPARTMENT
0 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 261
•a' - BUILDING DEPARTMENT
TOTAL DEMOLITION SIGN-OFF FORM
State Building Code (780 CMR) Chapter 33, Section 3303.6-Service Connections
"Before a building or structure is demolished or removed, the owner or agent shall notify all
utilities having service connections within the structure, such as water, electric, gas sewer and
other connections. A permit to demolish or remove a building or structure shall not be issued
until a release is obtained from the utilities, stating that their respective service connections and
appurtenant equipment, such as meter and regulators, have been removed or sealed and plugged
in a safe manner."
"All debris shall be disposed of in accordance with 780CMR 111.5."
Building or Structure Location: Sal , Sg14v4 red Map: Lot:
Owner's Name: 1-0,.,n kr,... -t. Address: Phone:
Contractor's Name: (Vw alv- Address: &co s- Phone: /-6 j 7- 54 7- 6c
Eversource: Date: 2706. rift, °tin'
By:
Title:
National Grid: Date:
By:
Title:
Water Dept.: Date:
By: S014 ) 1 5ck, '?"
Title:
Board of Health: Date:
By:
Title:
Condition:
Fire Dept.: Date:
By:
Title:
Historic Commission: Date:
By:
Title:
Conservation: Date:
By:
Comcast: Date:
3/15