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Home My WebLink AboutBLD-23-005533 10itce Use Oth 150-23-55-3 • Permit# e Amount Qt5 "''''JJJJJJ °'"°""° c0 �IPermit expires 180 days from {issue date RECEIVED EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH APR 0 5 2023 Yarmouth Building Department _. 1146 Route 28 BUILDING DEPARTMENT By: South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 22 P t a E CoN t DRIVE , WEST Y.AkMoc(l-1 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: WIWfJE L VSELLEE KUCNkl25Y1 22 PIIJC CDtJr hThJLc gal 58i a�q� NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# /' 0 0 ®Residential 0 Commercial Est.Cost of Construction$ 5,000 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 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:# Replacement doors: # I 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: 1 A& ct R Sii r O 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: I / Date: Owners Signature(or attachment) 144 " Date: /CJ/a0 Approved By: 'G� Date: Build": rc. or signee) to ./L 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 oflndustrialAccidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 0.1 www.mass.gov/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): WAyk)t 4- kt=L1..EL Address: 22, Pft) Cnl I UW E City/State/Zip: U12- lK Phone #: �' ai+9 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 2.01 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.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]I. 10 ❑ Building addition 4.V 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.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.E 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 under the pains and enalties of perjury that the information provided above is true and correct. Signature: U%A Date: 4176-1616-2 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#: f LI V/ AO cA,3 -519 ram} 1914._ 4 r�,•�/L i /sI?e,v w ' Z Stu crif /n! 34o�� ,✓� mied/M-2 Yea /01 eAk6 oS.l.�24/1__ pQ,�G�I' -- Olde A igeme u //1. 4e&' i 4 o?o kg' W2. itesld//' /N �4L , 2iz oloP 6' ive — • / A• L-d-/A 114 1 4 H H • . _ • ,. 06)