BLD-23-002576 r 9 '; j "({ (N C t C—(� - ;Office Use Only
'• r 4: Wit'+! '- PIA vt' 6( -111 Permit#/ A3
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/ 1 Permit expires 180 days from
Q L D -02 3— 'issue date
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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#: