BLD-23-005596 `OF•Y�R Office Use Only
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Q RECEIVED _Permit#
UC l Amount U
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APR 0 7 2023
*.°""'•Q72 ;Permit expires 180 days from =
{issue date
BUI T
By.EXPRESS BUILDING P IT APPLICATION
TOWN OF YARMOUTH j3u)_2,3--005S9,6
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
q (508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: e / OAk A VG-i al y10i'noat///
ASSESSOR'S INFORMATION:
f� ,,�J Map: �/ Parcel: / /
OWNER: /�.OL'6 tY•4/ SON Z�j 094 ry(G . Se -St?I bs te L/
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
CLO
Residential ❑Commercial Est.Cost of Construction$ /e 1Gi
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
),'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 Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 4 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: .,/mpia ?1 Y /6244/`'( .... s /4,
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: 0 ZQZ?
Approved By: i �-- Date: de ^7
Building Official(or designee) ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
''� •
The Commonwealth of Massachusetts
Department of Industrial Accidents
-fie 1 Congress Street, Suite 100
_'S•�=.� Boston, MA 02114-2017
�,'.IMP 5 www.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LetzibIy
Name (Business/Organization/Individual): k'o T� 7 J.A. /2 T 1/J
Address: Z 04 e i/C'-) /V, MV 'G'Gt��� /`'� ' (yci))
City/State/Zip: C&" VA'I Goa 7A/, �-�' �hone #: ' - 2e— % G
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp. insurance required.]
9. ❑ Demolition
3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 0 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 11.0 Electrical repairs or additions
proprietors with no employees.
- 12.0 Plumbing repairs or additions
5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs
ra
These sub-contractors have employees and have workers'comp. insunce.t "/;�
6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 1 Other/;��(1� I,-. -{���(�
152,§1(4),and we have.no employees. [No workers'comp. insurance required.] ,�1 ' /nw S /,jc t ECj 0 PL4(.
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. P2l f/i/�
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,an enalties of perjury that the information provided ab e is true and correct.
Signature: ✓�- (�ilt',ZG-r. "----, Date: 1/ 02,3
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#: