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Home My WebLink AboutBLD-23-005865 /3 I t�r r�y�v. g) I iPermit# O�.Y`qR 1i Amount O04 .\\.<tii, ryi i Permit expires 180 days from "3 j issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH I Yarmouth Building Department E VED 1146 Route 28 R APR 212023 South Yarmouth,MA 02664 (508) 398-2231 Ext. 12 BUILDING DEPARTMENT BY CONSTRUCTION ADDRESS: I Al0r -a/b/ ASSESSOR'S INFORMATION: Map: Parcel: mA ay 3 yr �3e j, � L. # OWNER: PRESENT ADDRESS V NAi� L.# CONTRACTOR: MAILING ADDRESS �. NAME Est.Cost of Construction$ t 0 Commercial esidential Supervisor Lic.# Construction Sup Home Improvement Contractor Lic.# Workman's mpensation Insurance: Icam the sole proprietor 0 I have Worker's Compensation Insurance am the homeowner Worker's Comp. y# Insurance Company Name: polic WORK TO BE PERF0— D Duration__� (Fire Retardant Certificate attached?) Wood Stove Tent Siding: #of Squares Replacement doors: # Replacement windows:#__ �_ Insulation__ ( )Remove existing* (max.2 layers) Roofing: #of Squares__— Ifiiiiiifencing Highway/Historic Dist. ( )Replacing like for like Old Kings Highway�� W *The debris will be disposed of at: Location of Facility a false answer(s) penalties of perjury that the statements herein contained are true and I.G.correct to the best of my Section knowledge and belief. I understand that any I declare under pen license s Z will be just cause for denial or revocation of my Date: `T 3t�- Z Z 3 Applicant's Sio:tore: /�� J_ Date: ment) ; �2.- Owners Signature(or a Date: — Lc Approved By: EN DRESS: 1 �- L0c4.4 l 01 a ilel Building Official de ' ee) Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No Within 100 ft.of Wetlands: Water Resource Protection District: ❑ Yes J No Yes 0 N0 \ The Commonwealth of Massachusetts Department of Industrial Accidents W�i== 1 Congress Street, Suite 100 =�A= 02114-2017 Boston, MA www.mass•z, dig R orkers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Leaibl A licant Information Name (Business/Organization/Individual): t Iti�21?/ Address: 2 ` �' 09- in a /, -sn Phone#: i 3 5 l'� 1S City/State/Zip: �;.Ju.�1 V,. Type of project(required): Are you an employer? heck the appropriate box: 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction g. �Remodeeling 2.01 am a sole proprietor or partnership and have no employees working for me in 9 Demollin any c acity.[No workers'comp.insurance required.] ,. 3. am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. _ 12 0 plumbing repairs or additions • ` 1;.Q Roof repairs 5 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. r�� These sub-contractors have employees and have workers'comp.insurance.t 14. • �ther it 6❑We are a corporation [ comp.right c. 152,§1(4),and we have no employees.[No workers' insurance required.] compensation policy information. *Any applicant that checks box#1 must also fill out the section below showing their workers'comp t showingorthe name hire the sub-contractors and state whether or not those entities have T Homeowners who submit this affidavit indicating they are doing all wor and then outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional provide their workers'comp.policy number. employees. If the sub-contractors have employees,they P er that is providing workers'compensation insurance for my employees. Below is the policy and job site Iama n employ information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: City/State/Zip: Job Site Address: showing the policy number and expiration date). Attach a copy of the workers' compensation policy declaration page Failure to secu re coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 imprisonment,as well as civil penalties in the form of a STOP e Ooff ORDER ions of the DIA forinsurance a day one-yearP day against the violator. A copy of this statement may be forwarded to the Office coverage verification. I do hereby certify under the pains and enaltie perjury that the information provided above is true and correct Date: Z Signature: Phone#: Official use only. Do not write in this area, to be completed by city or town official. Permit/License# City or Town: Issuing Authority (circle one): Ins ecto r 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing P 6.Other Phone#: Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." • An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will givenbe eas need only submit a reference b number. In a add d ititninding, an aappl cuanrrent t that must submit multiple permit/license applications in anyyear, policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially stamped o marked by r Sthe cityor. A new town mt ay be prov e filled ouo theh e applicant as proof that a valid affidavit is on file for futurepermits year. Where a home owner or citizen is obtaining a license or permit not wired to toco any buse iness is ssaf or commercial venture it. (i.e. a dog license or permit to bum leaves etc.) said person is NOT e q The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 o7r749 77-MASSAFE Fax# 61 www.mass.gov/dia Revised 02-23-15 40*"- CONSERVATION 4 OFFICE o �y kgrant@Yarmouth.ma.us Yarmouth Conservation Commission Yarmouth Conservation Administrative Review Comrmtssron Applicant Information: JUN 2.3 2022 `TD 4 G . Tie9k)c Name:Mailing Address: t! ? a C -u eit. sue• W A-L rl % d"l 5 3 Phone: ('?/ 1 8 l - G (`t S Email: U I I OC 44 /07 /c/ Jol Cep)? Signature: '"i (__- Location of Work: ) 9 /4 i ekit,v' 126 Street Name and Number Please Note:By submitting this application the applicant grants permission to the Conservation Office to enter the location to conduct a site visit(if needed). Detailed Description and Reason for Proposed Work: l p,j S a_ G /rafre f - b nc* £ vi,e,e o f /cam 'T) tsYic/ se P/ 70 f�j l ei . Closest Distance to Resource Area: f't. D Proposed Start Date: if S per 01 , ,7 Company to do Work: cc 4, Name: e € j c.e kn,9 N c7 R 5p Zr l,v s-7)w Address: Email: Phone: administrative Approval: 0 IC l r r '"6 it' . At , /r n AA; „,-.7/77:7, This approval is valid for one year. This Approval does not grant any property rights or any exclusive privileges;it does not authorize any injury to private property or invasion of property. Yarmouth Conservation Commission• 1146 Route 28,South Yarmouth,MA 02664•(508)398-2231•Ext 1288