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Home My WebLink AboutBLD-23-005775 -Y19 Office Use Only C Permit# O - y ESE "� -�Amount ;j d,OD cr\ Permit expires 180 days from issue date BLD EXPRESS BUILDING PERMIT APPLICATIONS —O05 7 7,5 TOWN OF YARMOUTH Yarmouth Building Department ' V 1146 Route 28 South Yarmouth, MA 02664 fpRig2o2j1 ✓- (508) 398-2231 Ext. 1261 iC� ', 1 ' BUILDING DEPARTMENT CONSTRUCTION ADDRESS: �/ �0 Z a CEO 6-rag fed • /�ar`fl jc�,) n';'� `�' ASSESSOR'S INFORMATION: Map: } Parcel: OWNER / -ii.)V ego x/451061) 6aqe 61, 77 7v1,67, 62/76 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Nl Residential ❑Commercial Est. Cost of Construction$ "750. ✓ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm Compensation Insurance: (check one) [B'I am the homeowner ❑ 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: # pC 1/ 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: Vd-/"/ree2th 7000/2 DiS' "�j7-3 / 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: Date:17- � Owners Signature(or attachment jr N Date: L�� /e"`'` /T iO p � Approved By: G�/�C�� Building Official(or desig EMAIL ADDRES Date: / / Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 7 No _*_� The Commonwealth of Massachusetts Department of Industrial _ ==�r� 1 Congress Street, Suite 100 ,1 ....•— Boston, MA 02114-2017 _ yl ..5°' www.mass.gov/dia Yorkers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ' / � of 1 v Address: 3q0 l/ b/ a'ra y �d. City/State/Zip: GU - ( at/1'200M Phone #: '77 V 7gp x/70 Are you an employer?Check the appropriate box: 1. I am a employer with Type of project(required): ❑ employees(full and/or part-time).* 7. 2.0 I am a sole proprietor or partnership and have no employees working for me in ❑New construction red. • 3.[y capacity.[No workers'comp. insurance required.] 8• El Remodeling I am a homeowner doing all work myself.[No workers'comp. insurance required.]ui t 9 ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 El Building addition • ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees. - 11.0 Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.* 13•❑Roof repairs 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 ant 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 do hereby,c'e ify under the pains and penalties of perjury that the information provided above is true'and correct. /§ianaturel l G ��ik Ai d7og, V Phone#: 77 78? /-77 Date: 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#: