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Home My WebLink AboutBLD-23-002470 {Office Use Only v, 0.1 1Permit# �//� ��7� O H' Amount `V .oO '� MATTACM LS[•�' "` °`°9 end' Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION. 0 E I V E 0 TOWN OF YARMOUTH Yarmouth Building Department NOV 03 1022 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 By: B ulL PI CONSTRUCTION ADDRESS: .J ?cc it/ R.t id -?c ASSESSOR'S INFORMATION: Map: Parcel: I C Ci I OWNER: �1-,C Pt-J"/E V S6, ?at Ai /Zit/c 72cl 6)/7— 633— 6.S y3 L' NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# IR esidential 0 Commercial Est.Cost of Construction$ 0 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman Compensation Insurance: (check one) 0'I am the homeowner ❑ 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. ( ) Replacing like for like Pool fencing *The debris will be disposed of at: riiI(A)/I/ DLL M Locution 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 for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sig vo ature: / r - 0 244�4A.e- Date:/V0✓ Oe 2 2 Owners Signature(or attachment) J/ Date: /f Approved By: Date: //— RESS:Building Official(orEM IL ADD Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 0 No --, IDE`m U - IHec i /� The Commonwealth of Massachusetts ,►* / Department of Industrial Accidents _L,el; 1 Congress Street, Suite 100 =1=•F=�< Boston, MA 02114-2017 '�..s'� _ 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): {vc- ( (C1 X. /✓F J V Address: /�u•,/ /or✓ / City/State/Zip: ,gi✓ V f},2 Itt0 k 7 /M7 D2O6v` Phone #: w/7` Ze3 3—6 S--z/_ 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.E I am a sole proprietor or partnership and have no employees working for me in 8. 111 Remodeling any capacity.[No workers'comp.insurance required.] 9. v'bemolition ` 3.2 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 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.E Plumbing repairs or additions 5.E 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.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. #: , l -�- Expiration Date: Job Site Address: 5-66 .0 A-) /J/,' )/ City/State/Zip:So /44 c)"7 re C ' / ' 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 p 'ns and penalties of perjury that the information provided above is true and correct. 4 A Signature: c'u.t,A,.. t 4 Date: — 3 — Z 2- / 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#: