HomeMy WebLinkAboutBLD-23-005917 O :jr-- - �/�70a� ;Office Use Only
•! RECEIVED J 1 Permit# '^�
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS:
ASSESSOR'S INFORMATION:
Q,l Map: i ',,�` Parcel: (�,, (� ,{ s�
OWNER:-UY O(. � �i �VNI„ `4,,,,6 ea. "l1D.-- 4.�s L_.1
NAME PRESENT'ADDRESS TEL. #
CONTRACTOR:
/ NAME MAILING ADDRESS TEL.#
4 Residential ❑Commercial Est. Cost of Construction$ / 00
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
❑ 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:# �j 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: \(OLV IY\ k\ --CLO �Location of Facility
I declare under penalties of perjury t �% ements 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 rev.y,3,'my license and for prosecution under M.G.L.Ch.268,Section 1.
�
Applicant's Signature: �/ /77
LDate: 0�L �
� � 3
(iOwners Signature(or attachment) Date: L Z-3
Approved By: Date: / i 2c — .3
Building Official(or design ' EMAIL ADDRESS:
Zoning D. rict:
Historical District: 0 Yes L No Flood Plain Zone: ❑ Yes '3 No
Water Resource Protecfs District: Within 100 ft. of Wet ds:
❑ Yes i3 No ❑ Yes No
,\
The Commonwealth of Massachusetts
:•!•�_ /, Department oflndustrialAccidents
1 Congress Street, Suite 100
-44=1 Boston, MA 02114-2017
www.mass.cxov/dia
«Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: A- V-ek .
Ci.ty/State/Zip: Maxry\ -1 (5"`$'hone #:C 16.3\4
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
3.2I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑ 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.❑Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.❑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.; 11
rAl
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other x��Ah
152,§1(4),and we have no employees. [No workers'comp.insurance required.] reQV
*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 certify de ins and penalties of perjury that the information provided above is/true and correct.
Signatures Date: Li /-z--j
Phone#: R7 A : I L/ /5, 1
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#: