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Home My WebLink AboutBLD-23-002447 1.1RR ' e cti w� l D1317e Office Use Only 'tea3� • � c Permit# ems-75 ; 17 O . H 'Amount tA etS)MATTACn CSE °°•°�°"4 Erd iPermit expires 180 days from 'issue date 6 LD -a 3- DDgLyzi7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146Route28 RECEIVED South Yarmouth, MA 02664 _ . �� -- (508) 398-2231 Ext. 1261 FNOV 01 2012 f _ CONSTRUCTION ADDRESS: I IOli (1T V�FP� BUILDING DE c "Y 1ASSESSOR'S INFORMATION: Map: '� Parcel: /d 5 OWNER: M �P L •L . 1-f tv I� T oveo 90'6 •2-Z1. O,`T3b NAME PRESENT ADDRESS TEL. # CONTRACTOR: / NAME MAILING ADDRESS TEL.# 1'J Residential 0 Commercial Est.Cost of Construction$ /5 Q 0 0 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman' 'Compensation Insurance: (check one) 'VI 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 XSiding: # of Squares 1 )(Replacement windows:# lip Replacement doors: # 2. )7C xRoofing: #of Squares i I/ ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 06:IS -M, (A.M T 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: Ai(a� Date: IY3i/W Owners Signatu (or a chment) Date: PAfrekiA Approved By: Date: /! h Z Building icial(or dens' EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No iif/!�/�/ f)i cFd/) bu U I f v%Q 4 Water Resource Protection District: Within 100 ft.of Wetlands: _ /l r+�_ 0 Yes 0 No 0 Yes _ No G `7 //t)i nl MI a perrni ]' LO �� 7s � 7s (5.� r-� =3 � S 0 f.S-Q - - /c 0 c._a The Commonwealth of Massachusetts M= s' Department oflndustrialAccidents g _ 1 Congress Street, Suite 100 1.0 =.V?i_ Boston,MA 02114-2017 �N�t-.- www.mass.gov/dia IMOWorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): W\p( Z,.C4 D V. meg_, Address: 17 TauzAii\jg ""`7 City/State/Zip:Sj Micro- , M1A621COPhOne#: 50rb ' 22 I• 0 Libb 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. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in c aci 8. []Remodeling • an y ap ry.[iio workers'comp.irsurance required.] 3. I am a homeowner doing all work myself. t 9. ❑Demolition ❑ gy (No workers'comp.insurance required.] 4."�.I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13•�t Roof repairs 6.0 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 S1,500.00 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sisnature: i�dneir-- Date: / �,S4'27 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: