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Home My WebLink AboutBLD-23-005596 `OF•Y�R Office Use Only "Iril Q RECEIVED _Permit# UC l Amount U ATT"ACH - d I 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#: