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01•Y. R E C NE I E D 5l 402 'Permit# ��11/%}/GOZ
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Permit expires 180 days from
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� ,_issue date
.— BUILDING DEPARTMENT
BY.----- 6 gyp- A3-666d‘3
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261
c 1 n e 9 r 6 5 4- S Uv �1-t-. tj r*�a-�
CONSTRUCTION ADDRESS: 15 �J �
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: WC.) r.S.,-< ' l% r,-e i3 v✓ .r.t•1 g--k S 7 7
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#o!J
esidential 0 Commercial Est.Cost of Construction$ C 0
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman.Workman .c ompensation Insurance: (check one)
-01 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 U Duration (Fire Retardant Certificate attached?) Wood Stove
III
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares , ° ( Remove existing*(max.2 layers) Insulation I I
El Old Kings Highway/Historic Dist. (Q))Replacing like for like Pool fencing I I
*The debris will be disposed of at: y C r'"0-'1 DU "' e
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: , 14-- Date: 5 f a/ a 3
Owners Signature(or attachment) tZ—lr-— �—_— Date: �5�� / 23
� Date: ����
Approved By:
Building Official(or design EMAIL ADDRES
Zoning District:
Historical District: CI Yes r] No Flood Plain Zone: C Yes L No
Water Resource Protection District: Within 100 ft.of Wetlands:
D Yes 0 No L Yes L No
The Commonwealth of Massachusetts
Y=.tlli / Department of Industrial Accidents
1!)= ' 1 Congress Street,Suite 100
K Boston,MA 02114-2017
yY'^•,�� Y www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Auolicant Information Please Print Leaibl'
Name(Business/Organization/Individual): Kb n c) - 0✓f s g
Address: 13 V h n t y c v S
City/State/Zip: 9 r-, . p 266), Phone#: 7Y I ' P50 - C 7 7 S
Are you as employer?Check the appropriate box:
Type of project(required):
1.01 am a employer with employees(full and/or part-time).* 7. D New construction
2.DI am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. Remodeling
3.tDi i am a homeowner doing all work myself(No workers'comp.insurance required.)t 9 Demolition❑
4.DI em a homeowner and will be hiring contractors to conduct all work on1 will 10 Q Building addition
ensure that all contractors either have workers'coproperty.
withatperrgation insurance or are sole 11.D Electrical repairs or additions
prop employees.
12.D Plumbing repairs or additions
5.13 am a general contractor and I have hired the sub-contactors listed on the attached sheet.
These sub-contractas have employees and have workers'comp.insuance t 13. oof repairs
6.0We are a corporation and its officers have exercised their right of exemption per MOL c. 14.D of
152,§I(4),and we have no employees.[No workers'comp.insurance required.)
'Airy 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 than hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not tbos entities have
employees. lithe sub-contractors have employees,they must provide their workers'comp.
p 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 S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 cenYfy under the pains and penalties of perjury that the information provided above is true and correct,
Signature: /
Date: S 3
Phone#_'7 6 l - c 5 0
Official use only. Do not write in this area,to be completed by cfty or town official
City or Town: Permit/License
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town CIerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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