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Home My WebLink AboutBLD-23-003739 1Ac 1gR Office Use Only'�C �'f.M .:�,aor•rto.p 7L� J A N 10 2023 ' Permit expires 180 days from i issue date BUILDING DEPARTMENT Gat. 1/ —7(40 BY. �/�-4 V EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 3_1)23-( 373? U South Yarmouth, MA 02664 �'V 1 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 11- if L , S Yak q14 t I-� r 1 O 2 G ( t ASSESSOR'S INFORMATION: Map:p Parcel: OWNER: OWL S� MI I @�` Jl , /is PRESENDRES .3 s.%ft"CaiI., ► 59$ . l f CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ S DC) — Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) II am the homeowner ❑ I am the sole proprietor 0 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: # 1_ 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: 10,41NIA1 k '0 k. i) 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 andn! for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 4 Slaii UvU Date: ( IC)/ 2 2 Owners Signature(or att ment) 0 Cy,, 4 hSi J Date: I / Id 2 015 Approved By: Date: If I M Building fficial or d ignee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes C No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 2 No • The Commonwealth of Massachusetts ""' Department of Industrial Accidents ei1= 1 Congress Street, Suite 100 • `=r Boston, MA 02114-2017 N.5,,v150. 4, www.mass.crov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ,, Please Print Legibly Name (Business/Organization/Individual): SZ &L. t HS t Address: 11/15 1 VOL f c c9ii L %DIY 00\41 L l h A , 02 66 y City/State/Zip: Phone #: ( 3 3 6 Lt i l g if Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. _New construction 2.�I am sole proprietor or partnership and have no employees working for me in 8. Remodeling an capacity.[No workers'comp.insurance required.] 9. 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.Q 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.1 14.0 Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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. tContractors 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: \(iL3 Z SA L MXdd i 010 / )- C7 Date: 2- 3 Phone#: cog - 3 ot - 511 1-f 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#: