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Home My WebLink AboutBLD-23-005874 "OF'Yeli RECEIVE D Office Use Only Permit# 0, 14 CI(4/ . ► APR 21 2023 jAmount CIO CO MATTA M ESE I `°"°°""`°�Q c d I Permit expires 180 days from BUILDING DEPARTMENT jissuedate ;y ___ 8 CD- 023 -6.05131-1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: SS0 4 iuc7 i o/ 5,0 �7A 1q-2 ry„,,o 4,7 /i f}- 0 2-C y ASSESSOR'S INFORMATION: Map: Parcel:OWNER: ‘ LxS A- CA-LL£ 0 re)a,eST/''W 5,4 -`ti/�2 ,n f�lf1' b26dL/( 4- 2oweseito NAME PRESENT ADDRESS TEL. # CONTRACTOR: // NAME MAILING ADDRESS TEL.#` b' esidential ❑Commercial Est. Cost of Construction$ /000.Jl) Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workmf�s Compensation Insurance: (check one) L4 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: Ut rAo k%51\ eri S✓ ti/. Pool. ID;spa Sal,1 Gl..+ Yar/v1,0 v rA n is 5to Sc I 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: C 14—2/ — _ 'L 3 Approved By: Date: 2 /%2-3 Building Off 'al(o esignee) EMAIL RESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: U Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes D. No • The Commonwealth of Massachusetts Department of Industrial Accidents � �e� 1 Congress Street, Suite 100 � _rrim b =�r_ Boston, MA 02114-2017 IMO www.mass.;o v/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): L. vas_ A . C',4GG Address: 4'5 e 5 7- City/State/Zip: r� 4 � - a26�LA Phone #: 6 / go o Are you an employer?Check the appropriate box: Type of project(required): LE I am a employer with employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. I]New construction any capacity.[No workers'comp.insurance required.] $• El Remodeling 3. 1 am a homeowner doing all work myself [No workers'comp. insurance required.]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my roe I will 10 [] Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.Q Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractprs have employees and have workers'comp. insurance.; 1 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. 1.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 pol cy 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 pains and penalties of perjury that the information provided above is true'and correct. Signature: Date: O —2- ^ Zo 2 3 Phone#: G O e2 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other P Contact Person: Phone#: