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Home My WebLink AboutBLD-23-002656 +'''".0. Y4 e L m/i /S _z 2 ;Office Use Only �! 0': I Permit# 1'41` S D *) 1 O . . H Amount MATTACI, eSE �' �,4°'°°'"`.1'E,`�' !Permit expires 180 days from !issue date esLD a 3 -Q&:26,5o EXPRESS BUILDING PERMIT APPLICATIO r`R E C E I V E D TOWN OF YARMOUTH - - Yarmouth Building Department [NOV 14 ZOZ2 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT }y L (508) 398-2231 Ext. 1261 By: _� CONSTRUCTION ADDRESS: d L1 L{ e % LimeS , Yctr ,01i ,/ �� l ASSESSOR'S INFORMATION: Map: /.� Parcel: 3 61 t9s0 OWNER: t tt it ..SCjyk, tl Y x� 0.5 �ti —7_ — 2 l-- ca�l d r NAI PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# )(Residential 0 Commercial Est.Cost of Construction$ 8 , 0 0 0,00 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) KI am the homeowner ❑ I am the sole proprietor U 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 1 O (X)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: YILVIAA0 OtL L..4. —R a . 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:Owners Signature(or attachment) Date: L,'r t 4—a i I _/32 Approved By: Date: `/ Building Official(or d nee) ENTAIL ADDRESS: 8k. Ce-ti Oka, ha-&t wad 1• cow. Zoning District: Historical District: ❑ Yes yK No Flood Plain Zone: Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes No 0 Yes X No The Commonwealth of Massachusetts +�, _ Department of Industrial Accidents _nr%'11= 1 Congress Street, Suite 100 _I�- <NIP Boston, MA 02114-2017 .•`''y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): 41,111. i , 5cit 14d4;taiiik Address: 3 4 tithe IDq rr vl- City/State/Zip: , YCU�W�� ;�- Phone #: 74 6,3C) 1 G " 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. ❑ New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.]t 4. myProPenY�I am a homeowner and will be hiring contractors to conduct all work on 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1:37fg.Roof repairs These sub-contractors have employees and have workers'comp. insurance. 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 certi under the painns`and penalties of perjury that the information provided above is true and correct. Signature: ,�-� �r""^t't� Z� Date: I (—1 (4',? 3— Phone#: 7 3. t — la.30 .—/7..),-c- 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#: