The URL can be used to link to this page

Home My WebLink AboutBLD-23-005549 R E C " IVED Office Use Only . i r Permit# } , s APR 0 5 2023 0 $: — Amount 5U.CO ! i ��sE o./ :W1, BUILDING DEPARTMENT Permit expires 180 days from BY - -- issue date EXPRESS BUILDING PERMIT APPLICATI(t C E I V E D TOWN OF YARMOUTH Yarmouth Building Department APR 05 2023 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 By — 36 CONSTRUCTION ADDRESS: Crowes Purchase Rd ASSESSOR'S INFORMATION: Name Reverse Party Town Rare Map:`'°" "; ` ""�""°`� R Parcel: Steven J./Maureen Lampa 36 Crowes Purchase Rd 978-855-2171/5084791819 OWNER: NAME PRESENT ADDRESS TEL. # CONTRACTOR:Self NAME MAILING ADDRESS TEL.# B Residential 0 Commercial Est.Cost of Construction$ $10,000 Home Improvement Contractor Lic.# Construction Supervisor Lic.#?to1 Workman's Compensation Insurance: (check one) e I 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 U Duration (Fire Retardant Certificate attached?) Wood Stove 111 Siding: #of Squares 10 Replacement windows: # Replacement doors: # Roofing: #of Squares (El)Remove existing*(max.2 layers) Insulation l l nOld Kings Highway/Historic Dist. Replacing like for like Pool fencing 17 Yarmouth Construction Landfill *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the tate r is 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 o revocatio. ..my I\and for prosecution under M.G.L.Ch.268,Section 1. 04/05/2023 Applicant's Signature: Date: 04/05/2023 Owners Signature(or attachment) Date: Approved By: Date: —�� Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts t 111 Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass aov/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): Address: City/State/Zip: Phone 14: Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 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. [No workers'comp_ insurance required.]t 9. ❑Demolition 10 n Building addition 4.0I 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,nElectrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0I 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.: 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§I(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 41 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. ttContractors 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: 04/05/20233 Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: The Commonwealth of Massachusetts ►�_' /, Department of Industrial Accidents e1 Congress Street, Suite 100 7.-. 4_ <' Boston, MA 02114-2017 ,.: www.mass oov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,!) v e/') jr L a Vy1 on_ i Address: ,3(,) (ro toes 19 rs U!f a,$ City/State/Zip: I { Ya j31 tit-A Phone #: q7, -F1,575 '021. 7 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 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 ❑ Building addition 4.0 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,❑ oof repairs These sub-contractors have employees and have workers'comp. insurance.: 1 n 14. Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: < Date: Phone#: rg 1 "5 75 5 r2 t 7 • 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#: