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Home My WebLink AboutBLD-23-005493 �Q 2 I �O1.•YaR RECEIVED 'O ev..) y_3 _a ;. 4y93 .„r O j p G] k... ..,. Amount / f�,F:d EAr5APR_. 0 41023 �I �+W�t*"°�."°��' 1 Permit expires 180 days from BUILDIN DEP�R MENT ' I issue date By: EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Q y 016 t-Lt... i n is . ASSESSOR'S INFORMATION: \\II .A eleat10,Map: \ Parcel: 11�� C)OWNER: JV \ '\`'� O\ ( ►1n IS 26 1-� s 2,o �31 d NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est. Cost of Construction$ %1 ( VO Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one)0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insuran e I C p�, p Insurance Company Name: Worker's Comp.Polic v Q,bn \12/ WORK TO BE PERFORMED Or .o u ' 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: Location of Facility I declare under penalties of perjury that the s ents herein e 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 revocatio or prosecu' n under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Aprt( q i aoas J I Owners Signature(or achment) Date: ✓� Approved By: Date: /�/ Building Official(or des ee) EMAIL ADDRE Zoning District: Historical District: 0 Yes 2 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts _W, = Department of Industrial Accidents =�rAl- 1 Congress Street, Suite 100 =��=' Boston, MA 02114-2017 `,' 5.•`'. www.mass.gov/dia IMP \ol-kers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): , >7 -V.K.\ (\.C\ Address: C \ N. \-� (' :00\`- City/State/Zip: (O Tv A P0i 1 HP\ 01911phone #: N a 3S-N Are you an employer?Check the appropriate box: Type of project(required): l.r 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.] — I am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp.insurance required.] I am a homeowner and will be hiring contractors to conduct all work on my10 ❑ Building addition 4. ❑ 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.❑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.1 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 certify uncle z ins and p ties of perjury that the information provided above is true'and correct. Signature: Date: 1iprl( ` I 1 4 Da3 Phone#: (.9 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#: