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BLD-23-006062 i L3� ' Office Use Only Permit#cam#J97/,//�� J�/a�tAmount S(J-UtJ. an„n.» „, Permit expires 180 days from issue date Ig ,/)—a3- d®',o 2— EXPRESS BUILDING PERMIT APPLICATION TOWNOFYARMOUTH RECEIVED Yarmouth Building Department - 1146 Route 28 APR 2 7 2023 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT BY CONSTRUCTION ADDRESS: D` f l f //: . ASSESSOR'S INFORMATION: IMap: !9 I Parcel: /S'- OWNER: l: � / A . f),,I,v19J1z, NAME PRESENT ADDRESS TEL. # CONTRACTOR: jer j,>'<,� /I/;r. jz f' _''' Z/ G w,i..4/ /f/,/4'/'c v1 c/j t'- i '' r NAME ..a C � Y�'/>ar/.7... MAILING ADDRESS TEL.# El/Residential °Commercial Est.Cost of Construction S !th.9O Home Improvement Contractor Lic.# /2/ 'I - Construction Supervisor Lie.# ('r /_ .1/ Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor EI I have Worker's Compensation Insurance Insurance Company Name: 4'/z"1 f t''1iv,n L ,v c' Worker's Comp.Policy# ,4tc.' >0:4.Yob avoid. WORK TO BE PERFORMED Tent J._..! Duration (Fire Retardant Certificate attached?) Wood Stove El Skiing: #of Squares Replacement windows:# / Replacement doors: # Roofing:( ' #of Squares (❑) El Remove existing*(max.2 layers) Insulation EI ( Old Kings Highway/Historic Dist. (J)Replacing like for like Pool fencing ri *The debris will be disposed of at S J 44/4/0 l'v a -''t. 4 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; .fret..- t,,, Date: ,`! y ,; Ci?s Owners Signature(or attaehmen / 1 ! L ' Date: Approved By: t �� - Building Oft ial(or.. '.-,1 ey EMAIL A ESS: Zoning District: (� Historical District: 1 Yes ! No Flood Plain Zone: Yes I No '' 1 ' ' Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes ,, 57 9✓C1JO -_do q171 No The Commonwealth of Massachusetts Department of Industrial Accidents �!!.= 1 Congress Street,Suite 100 _:7.V Boston,MA 02114-2017 www mass gov/dia Workers' ompensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A. .I' ell Pt :se Print Le Name(Business/Organ` ;'on/Individual): •;s 0\ 1 US-R, b (l4 C. b+''1 "Ivi C . , - i1 M 'J�'.J7�uI,j P Address: d IL A. City/State/Zip: ■ S f Uul i d,,1 O . (kg Phone#: ,Tee' 0- : 1 a 8 Are you au employer?Check the appropriate box: 1. I am a employer with Type of project(required): ❑ employees(full and/or part-time).' 7. 0 New construction 2.01 am a sole proprietor or ership and have no employees working for me in any amity.[No -'comp.insurance required.] 8. Remodeling❑ 3.0 I am a homeowner doing- 1 work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and I be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all con. u. either have workers'compensation insurance or are sole proprietors with no=pi, . 11.❑Electrical repairs or additions t am a 12.❑Plumbing repairs or additions 5. ❑These and I have hired the sub-contractors listed on the attached sheet employees and have workers'comp.insurance t 13.❑Roof repairs 6.0 We area corporation: its officers have exercised their right of exemption per MGL c. 14.❑Other 152,11(4).and we have .employees.[No workers'comp.insurance required.] {Any applicant that checks box I must also fill out the section below showing their workers'compensation policy information. Homeowrers who submit this a,,.: ' indicating they are doing all work and then hire outside contractors must$Contractors that check this box ust attached an additional sheet showing the name of the sub-contractors and state whether or not thosebmit a new affidavit.. such. ndicating entities have employees. If the nr. have employees,they must provide their workers' . �. comp.policy number. I am an employer that Is a roviding workers'compensation insurance for my employees. Below is the policy and job site information. Corance Company N- A 11 1 N VAru L t�S v 11 A i.i CC l.. M4 r. Policy#or Self-ins.Lie. tC ()(U 464 C ) (� — � AVE. � � � Expiration Date: 6 -1 3- ��•;Z Job Site Address: _7 ko iq1 n ' t ' Attach a copy of theT wo ers'compensation policydeclarationCity/State/Zip: t} 1")-) YW10„) Ki page(showing the policy number and a iration date). Failure to secure coverag, as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year impriso , out,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. copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under e pains and Penalties ofperjury that the Information provided above is true and correct. c„:'?" � s e AP .. 5114 D. • ca 1"/ `2v Official use only. Do of write in this area,to be completed by city or town offlciaL City or Town: Permit/Lic, nse# Issuing Authority(d le one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: y . . . comm_weam of Massachusetts Division¥Professional L� mA■ -� Board of Building Regulations ands■nar .2 cis114. % pervr cS-05314 y & r s mf2023 . = -, . » � 2 y> , KEVIN MB \; ew 7 �«� & / � a . ,m�W 3 ^« > \ — © </ x ? : • HARWICH \ \ 6 ¥ ( ' ; . * »^ \ Commissioner d &. K. � ::c: ?ate 6 _ m 3 33•pz • S m > I - PI 0 i . -0 i. 0.... A 0 co g , 1.. g $0 c 1 t civ b I © _ 1 §r i , 0 ® 00 � � opp Bo 3 z co` - 5. 0 iry a1 - s . ! t ) ' !I 1 i . .,.,.. , . , 8 o I'a s; oo .ica ig �� 0 � � c �' o o co m II 1 1 i a. 5 . I t a i