HomeMy WebLinkAboutBLD-23-006022 .04,,YAR 0 a`/ X7,� /J Office Use Only
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building DepartmentTM-
1146 Route 28 MAY 01 2Q23
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
BUILDING DEPARTMENT
By,--- ------------..__
CONSTRUCTION ADDRESS: \O'6 ' \M CctjcwN \ �yr�E'% f4, "\?,S
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: CJ2i•- ML O' CO cri.W., Gd6" SNA --S :%ek
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: tAta►aCZANA:2;,k-1 .cl i. \r\�. 43 VA. t'\. •43 ' )CY OPS 5(A." 63 = i\
NAME MAILING ADDRESS TEL.#
4
Ii4Residential ❑Commercial Est.Cost of Construction$ 1 cs
Home Improvement Contractor Lie.# I /d gZ Construction Supervisor Lie.# C„S _ "' ' \
Workman's Compensation Insurance: (check one)
0 I am the homeowner ❑ I am the sole proprietor AI I have Worker's Compensation Insurance
Insurance Company Name: C V'J Z.S Worker's Comp.Policy# osblvii„- t'\ c tag- 22
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: gt]C-r\-0-M-\\_ 0..1riQ
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 revoc . of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: —� Date: S-\-- Z°3
\.
Owners Signature(or attachment) Date: '\ 7:3
Approved By: _ Date: V / 2 3
Building Official(o sig EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes E No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
C Yes ❑ No ❑ Yes ❑ No
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The Commonwealth of Massachusetts
L Department of Industrial Accidents
=�el� 1 Congress Street, Suite 100
• _ •�_ Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): V\ 1cl.1 �3NA,c. 4D-RIA
Address: G-k2
City/State/Zip: "It- t- N-kM 016-13 Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
I.R1 I am a employer with employees(full and/or part-time).* 7. E New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
9. ®..Demolition
` 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t
10 Building addition
4.0I 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.Q Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.01 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.$
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: C.\\v c 5 \t- 09- e\` �2 V`t
Policy#or Self-ins.Lic. #: 6'5401LwV4S• "v1.14„ Expiration Date: -c&g63
Job Site Address: \c C City/State/Zip: 4 , .,, t' '�. Zkg[
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 unde he pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: —\Z3
Phone#: S
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#:
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