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Home My WebLink AboutBLD-23-002576 r 9 '; j "({ (N C t C—(� - ;Office Use Only '• r 4: Wit'+! '- PIA vt' 6( -111 Permit#/ A3 O/l ,,, . "3. i I - Amount (0/ MATTAI M CS �' 4O+....,0 p,ica,i / 1 Permit expires 180 days from Q L D -02 3— 'issue date 4/a025-')10 E D E i EXPRESS BUILDING PERMIT APPLICATI l - VED TOWN OF YARMOUTHL NOV 0 8 2022 Yarmouth Building Department 1146 Route 28 _._... BUILDING DEPARTMENT South Yarmouth, MA 02664 By: (508) 398-2231r Ext. 1261 • CONSTRUCTION ADDRESS: II V\h�^frw07 12' S. 43n. ASSESSOR'S INFORMATION: Map: Parcel: , OWNER: IC/41 1�,.v,V,C1,l I 1 77g-3 2—2 3R NAME ( � w�.�c ►,L'/PRESENT ADD TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ G (, -i csv Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 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 -2/etAz--r5 Siding: #of Squares Replacement windows: # Replacement doors: # E5tY'c-brrS 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: 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: I.(/,e(""/ •)- Y Approved By: Date: //�-�; Building Offici de ' ee) EMAIL SS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No i The Commonwealth of Massachusetts =' Department oflndustrialAccidents =va= 1 Congress Street, Suite 100 • iTi Boston, MA 02114-2017 = www.mass.go v/dia us \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly //!! Name (Business/Organization/Individual): 1l�.et`1/4( L._/ //..—,v,u,...r.._ 1 L, Address: I ( \.1 .'L„,,,-, v.a,Y ad_ City/State/Zip: 5. Yc...c )---e, Phone #: ? ( 3� 3 — 7 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. E New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling anyacity.[No workers'comp.insurance required.] 9. CI Demolition ` 3. I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 E 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 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 6.❑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. 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 hereby ((tfY un er the phi s and penalties of perjury that the information provided ab ve ' true and correct. Signature: Date: t C S/ Phone#: 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#: