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Home My WebLink AboutBLD-20-4012 y Ohce Use Only o •Y�R 4.' • r+! QC Permit t 0 . • H Amount (/ a ` MATTACII CSE ' ` �'°°"°"`�9 j Permit expires 180 days from _ ='"';'",. j issue date ECi l/-4Di2 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 � . South Yalunouth, MA 02664 (508) 398-2231 Ext. 1261 �� ` " CONSTRUCTION ADDRESS: ft 7 &it( Cs(t Zc/ :, ASSESSOR'S INFORMATION: Map: Parcel: er OWNER: l01 ete V )110 • NAME PRESENT ADDRESS 'e TEL. # 3� . (S CONTRACTOR: (f�d) /Za)&4144, 1y).. 5f 6 j (s�6 b c1,- � fl `� NAME MAILING ADDRESS TEL.# ❑Residential A Commercial Est. Cost of Construction$ Jr OOO Home Improvement Contractor Lic.# Construction Supervisor Lie.# CS - /II 2 f3 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor L'A.I have Worker's Compensation Insurance Insurance Company Name: Af4., 014,401, t ith !< y Worker's Comp.Policy# /'Z q I4 WORK TO BE PERFORMED Tent Duration /) 01t9 (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 COri —Fr *The debris will be disposed of at: `"" v' Vi ro f OA. r)(9 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 revoc n° l' license and for prosecution under M.G.L.Ch.268,Section 1. ,4plicant's Sig, a -. L Date: (� k) - ZD ZO Owners Si! ature(or att chment) Ar` Date: ///'6/2-p Approved : --• AW. -- Date: / '/ 2. e- Building•'Kai(01 EMAIL ADDRESS: 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 14- r Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 !A; �,M,�s 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): 6'U 1 Address: Mi/} ieL,,) Si. City/State/Zip:_-,,',, 6osAvi. 144, 02. 1 Z C. Phone #: O —G 17— 667- ,wZa Are you an employer?Check the appropriate box: Type of project(required): l.X1 I am a employer with '1 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. Ili Remodeling any capacity. [No workers'comp.insurance required.] —3., I am a homeowner doing all work myself. 9. _ Demolition y [No workers'comp. insurance required.]'� _ 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 11.1] Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 6.]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurance.'< 14.ZI.Other % -��p� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. � itt, 152,§1(4),and we have no employees. [No workers'comp. insurance required.] rA J to *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: 19✓Y'b v /kit (i4kit -; £i i.-i eic Policy#or Self-ins.Lic,#: iqztlif Expiration Date: "'I-/ 11,71 Job Site Address: J ol 64,4_ t /e .I a City/State/Zip: Vit/0142A11/ /JZB73 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 t e pains and penalties of perjury that the information provided above is true and correct. A Signature: PDate: /^IO -ZZzo Phone;: /'- t)i- 7Ln/D LIT? 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 4: