The URL can be used to link to this page

Home My WebLink AboutBLD-23-005971 • --- RECEIVED vp�/ ;Office Use Only r� °� RR ;?", E C E I V J,/aQ j f i) —Z3—e / 'jam `, k .. ... L 0u , li �`[ . 11 �� 1rt7 023 Amount •�G MATTACH C$E )) 1 1\ 2 2 I d / „ Permit expires 180 days from LIL______________11-L-D- ING iJEPAR ;issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231nnExt. 1261 CONSTRUCTION ADDRESS: �' 6` f E t•y(4 f`X. J ' 4 rty,d. ASSESSOR'S INFORMATION: / Map: Parcel: OWNER: ( ..'• N & �. I *n it" (~1 p l . /4, 1`} it-, (�� '" l�(n — I�°I L t PRESENT ADDRESS ! v TEL. # CONTRACTOR: fL ' NAME C r MAILING ADDRESS TEL.# ❑Residential 0 Commercial Est.Cost of Construction$ -44.J42f '''- Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman' Compensation Insurance: (check one) I am the homeowner 0 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 ,... -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: / h ,lO LZ/f/ viz b Pic( L_. 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. App cant's Signature: Date: Owners Signature(or attachment) Date: 4-1 9`..l 7 Approved By: - Date: 4�--. ?.-- 1 Building Official e ' e) EMAIL ADD Zoning District: Historical District: ❑ Yes , No Flood Plain Zone: ❑ Yes U No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes ❑ No ❑ Yes 0 No The Commonwealth of Massachusetts ��='; /, Department of Industrial Accidents =tz= Il 1 Congress Street, Suite 100 _�s�`=1" Boston, MA 02114-2017 5�,� www.mass.gov/dia MP \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly t. Name (Business/Organization/Individual): kr,,,.,(Z_ L, M vn±b,. Address: L`� d i�p_ J -A,, (.( ra.,(. Ci. /State/Zi �a L6`—ty P� .'� , 7� M�� rhlE Phone #:"lny' ) 9 (�� tGf' '� 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. ❑New construction 2.0 I a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling a. capacity.[No workers'comp.insurance required.] 9. ❑ Demolition ` 3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 ❑ Building addition 4.❑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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp. insurance.$ 6.0 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 dhereby certify under the pains and penalties of perjury that the information provided above is true and correct. jo nature: �,r7�✓l / illVL,r „— Date: 4 -a/) 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#: