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Home My WebLink AboutBLD-20-4010 Office Use Only Y . ' AR`r � 'Permit# � t+! O ;Amount O . • H MATTAM C ESE r,,� ' At..k..Eorp:tp, !Permit expires 180 days from : issue date BCD, 0I D EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 + 0,; (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: `1 i 9 4/7I (5 4d ^ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: linitiV1 al IL / Ur`'G Z(�,� NAME PRESENT ADDRESS TEL. # �g! O CONTRACTOR: 614) Ai, /Z12-('jn n Suip al rX. 6 6f,4i /l O(ii, /°-4/7 3-4 7-C iet. NAME ING ADDRESS TEL.# ❑Residential iiti Commercial Est. Cost of Construction$ # g 7 IvD Home Improvement Contractor Lic.# Construction Supervisor Lic.# C S i l i In Workman's Compensation Insurance: (check one) ❑ I am the homeowner D I am the sole proprietor jj til I have Worker's Compensation Insurance V rfl'h Insurance Company Name: 1 ggc.4/ C;441'/1 r"f Worker's Comp.Policy# lei Zit 4 WORK TO BE PERFORMED Tent Duration /( 41j) (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: COO—C4/1116 71 110 rr 1e r- 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 revocation. y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sip a. Date: 0 o/2.0 br , 1 Date: /-j0—,020 - ��Owners "bnature(or .ttach � 1 , 4�� Approve. �/_ / Date: / Bui .mg I'iciT(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: D. Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No . The Commonwealth of Massachusetts i/, Department of Industrial Accidents ,y 1 Congress Street, Suite 100 ' Boston, MA 02114-2017 ^M r 5�.�' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): 411114.) 6r4i Address: /709 4ey7i / cf City/State/Zip: E. 604.1 /WA/ 07/7r Phone #: / -/?--j bs) r &WO 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. I am a sole proprietor or partnership and have no employees working for me in 8. n Remodeling any capacity. [No workers'comp.insurance required.] 9. C Demolition 3.-I am a homeowner doing all work myself. [No workers'comp.insurance required.]t — 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 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.C 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 % e✓YJ �6'Ei�. 152,§1(4),and we have no employees. [No workers'comp.insurance required.] "roild t.T *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. T-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: 4-/^✓$,Q 1/0i44,/ i"'Alit 71 l S Ar n vr4e — Policy#or Self-ins.Lic. #: /4li aExpiration Date: i l Z.fa2 Job Site Address: .5/9 I S& 1 fed City/State/Zip: !a nekozA aid, 6Z673 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 de< the pains and penalties of perjury that the information provided above is true and correct. ' / Signature: ® * Date: /'/b-POZO Phone#: /I 116)7-12i' - t2J77 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#: