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EXPRESS BUILDING PERMIT APPLICATION 40
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 C)"'
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: I S `J 1 YN.e LJ 4 v Z S.4- S U�l-1, J c,v' ..—J.-J1 /
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: KC)rS1-cr\el' kr.-e n(-)‘-irWI--- S0 C,C ! ra , ,}- r.`l 711' E-So • G779 ✓
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
❑Residential ❑Commercial Est.Cost of Construction$ I CC) 00 /
Home Improvement Contractor Lie.# Construction Supervisor Lic.#
Workman' Compensation Insurance: (check one)
✓am the homeowner ❑ I am the sole proprietor ❑ 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
1..„.- Siding: #of Squares -7 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 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: �//
✓wners Signature(or attachment) 1 Lam' Date: � c
/ / ()'V--7
Approved By: i1� L!Date: / ',
Building Offi ' (o esignee) E ADDRESS:
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes C No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes 0 No ❑ Yes ❑ No
The Commonwealth of Massachusetts
•
r /, Department of Industrial Accidents
___ j;_ 1 Congress Street, Suite 100
c Boston, MA 02114-2017
www.mass.gov/dia
MP
` «'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Please Print Legibly
Applicant Information (/
Name (Business/Organization/Individual):\A-0 n S a-�CN..)-t -e av`-)s ‘ -its 9 I
if
Address: l S V l .•e a r S d •
—
City/State/Zip:S J5v•""-'—d4.` c.,D_GG y Phone #: .--7 , I - S-SU 6 7 79 c__.,
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. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
an capacity.[No workers'comp.insurance required.] 9. ❑ Demolition
' 3, a homeowner doing all work myself[No workers'comp.insurance required.]t 10El Building addition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 12.0 Plumbing repairs or additions
5.1: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.; I4.❑Other
6.0 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:
2-' Date: 5'7V/aci 2,S
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
Phone#:
Contact Person: \
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