HomeMy WebLinkAboutBLDX-23-12506- ;Office Use Only
:01•Y � }Permit#
'Amount r
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,�,k0+0n0 Permit expires 180 days from
i issue date
MAY 31 2023
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EXPRESS BUILDI .`_Y ' 1N - LICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
C.
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 8' N4 6,L
ASSESSOR'S INFORMATION:
�� Map: Parcel:
OWNER: in)Lk+�-,-- P'1
�,�A SC( �I �\-3
N PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.(#%`
❑Residential 0 Commercial Est.Cost of Construction$ /I/O,C i/
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman' ompensation Insurance: (check one)
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 %,.3 ✓ Replacement windows: # !I ✓ 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:
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 licens Tor rosecution under M.G.L.Ch.268,Section 1.
A plicant's Signature: Date:
Owners Signature(or attachment) Date: S , /--'
Approved By: Date: n j(1J
Building Official(or designee) EMAIL ADDRESS:
' 4 ' `'//v-
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No ❑ Yes 0 No
The Commonwealth of Massachusetts
= _ 1, Department of Industrial Accidents
_VIM. 1 Congress Street, Suite 100
• _ �= Boston, MA 02114-2017
s+• b
www.mass.g'ov/dia
OOP
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ` Please Print Lezibty
/Narne (Business/Organization/Individual): 4„,., ,_,,,_ d,
Address: b')- V.K))2,-lXy(Nite <;(A L----,
City/State/Zip: Ai - (0\)\,\,0q)--\;\ , 00f Phone #: ., -k( -Y-2. ) ? " ...
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 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
3.0 I . a homeowner doing all work myself. [No workers'comp.insurance required.]t
10 ❑ Building addition
4 tr, 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.❑Roof repairs
These sub-contractors have employees and have workers'comp. insurance.:
6.❑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 d ereby certi unde ze pains nd penalties of perjury that the information provided above is true and correct.
ignature: Date:
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#:
(9ut
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