HomeMy WebLinkAboutBLD-23-002469 fir'�, 'a I Office Use Only
� � i Permit#
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IPermit expires 180 days from
I issue date
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28 �--�------�----_-----_
South Yarmouth, MA 02664 NOV 0 4 2022
(508) 398-2231 Ext. 1261
/� LDING DEPARTMENT
CONSTRUCTION ADDRESS: 2 r+ 04" C Qv.s C rt.L Yekr1�KL" B�
ASSESSOR'S INFORMATION:
Map: ^^ Parcel:OWNER: ).Q1J/`) Alarbo IJ�C d� P�4 SMA' C du— C (C.t.t 54-)o�f_.23 2-9?99
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
kRisidential ❑Commercial Est.Cost of Construction$ 50OD.(�
Home Improvement Contractor Lic.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
I am the homeowner ❑ I am the sole ptoprietor ❑ 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: # ' L Replacement doors: #
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: 5 Q T1 exc.
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 I.
Applicant's Signature: Date: 1i. /y(3-2--
Owners Signature(or attachment) Date: t
Approved By: Date:
Building Official(or design EN L ADDRESS:
Zoning District:_
Historical District: >( Yes '❑ No Flood Plain Zone: ❑ Yes .sX' No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes .4 No 0 Yes No
The Commonwealth of Massachusetts
+. _. 1 Department of Industrial Accidents
=Le= 1 Congress Street, Suite 100
10,
•w .r Boston, MA 02114-2017
°��:.=.•�'y Workers'
www.mass aov/dia
�� Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): , �
py� ' '- o -t-
Address: OL-et%6,(A- C C Y r
City/State/Zip: "Cq,,.,,- & I(),) - 0A7 S Phone #: -
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. New construction
2.E I am a sole proprietor or partnership and have no employees working for me in 8. — Remodeling
any capacity.[No workers'comp.insurance required.]
9. _ Demolition
3. am a homeowner doing all work myself. [No workers'comp. insurance required.]t
10 n Building addition
4.E1 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
5.1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof 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.❑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 certify under tl�wins and penalties of perjury that the information provided above is true and correct.
Sig
Sig-nature: �` �a�
`-� ��'"� ��� Date: � / ;
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#: