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Home My WebLink AboutBLD-23-003748 ]Office Use Only •Yd RECEIVED IPennit# Amount SD :A` „„rT,,c” LSE d$, JAN 10 2023 \�,a•.«o"9 Permit expires 180 days from I issue date BUILDING DEPARTMENT By. ---- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 [1 CONSTRUCTION ADDRESS: of It) f L.,j> fa 2$� r-ei gAtz- cJ : ASSESSOR'S INFORMATION: Map: Parcel: p OWNER: C'L) W 4-2Q moo 0251 IV/CD Txc6r- rem- a.. yfitichA (rt. 3 6 Y a 6 e/✓ NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ 3,Ooo..j-5 4/ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman>Compensation Insurance: (check one) &Y' am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (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. (1/'Replacing like for like Pool fencing NIA4 A -I%VI ivy It tt. - c vtozl ,ye j ,OOjtc- 0�I�2� / -44",.'1 *The debris will be disposed of at: / cs,r-t. 6� yj�L+�cu cc Z f� 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 of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachment) Date: ////O/2 3 Approved By: Date: / Oh 3 Building Official or designee) EMAIL ADDRESS: f 6 oe .6? c Zoning District: Historical District: B Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No 0 Yes ❑ No The Commonwealth of Massachusetts - A _. / Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 •,M= 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): k./9/Z,v 7-6-0,1) ,Address: aV w i L!0 S G --- 7-,4E k, -C?- City/State/Zip: S y/47PCit,-6 �iIY`j fi/ 0 Phtne #: 3-0 Co 61 6 g / Are you an employer?Check the appropriate box: Type of project(required): I.E I am a employer with employees(full and/or part-time).* 7. _New construction 2.E I am a ole proprietor or partnership and have no employees working for me in 8. E Remodeling an apacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]I. 9. ❑ Demolition 10 n 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.E 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. 00f repairs These sub-contractors have employees and have workers'comp. insurance.t 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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. 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: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 ereby certify under the pains and penalties of perjury that the information provided above is true and correct. ignature: 5:p„,....'�; % Date: //C /2 3 Phone#: i., S 47 gI 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#: