The URL can be used to link to this page

Home My WebLink AboutBLD-23-005847 .1(4.41i YR ,e 1 Office Use Only R P (fly $` '' ir•; i Permit#L;�#)J9) o ; , /21/ ,moo.Oa Amount �� MATTACM CSE•�'1 4�oaata b d,' Permit expires 180 days from issue date 6L-9 -023-056N EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 APR 20 2023 South Yarmouth, MA 02664 K (508f) 398-2231 Ext. 1261 BUILDiNC� DEPARTMENT NSTRUCTION ADDRESS: 5 elt/ 0 l��AI e 5 - j' ( �J ASSESSOR'S INFORMATION: Map: �i Parcel:� � L-�/ OWNER: L NNemar � 5e ' 1 c�i o Cn �J i 7- /? �'/ NAME PRESENT ADDRESS TE—. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est. Cost of Construction$ / / (h)[) . 619 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) VI 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 V/ 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: 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: Owners Signature(or attachmen Date: 4/1,20A 3 Approved By: Date: 7 2/ 3 Buildi ff (or signee) L ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: a Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No 0 Yes No _ = • The Commonwealth of Massachusetts A _*_, = Department of Industrial Accidents _�/11= 1 Congress Street, Suite 100 _?e �_ Boston, MA 02114-2017 s www.mass.gov/dia \orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly tame (Business/Organization/Individual): I( Q/'j tee/ Address: ;�e /2J c I/� , . J City/State/Zip: ,5, (`,�oMA,{ Phone #: .6 / 7 --CF — 6 , ---C j Are you an employer?Check t e appropriate box: Type of project(required): LE 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.] ` 3. I a homeowner doing all work myself. 9. El Demolition ❑ y [No workers'comp. insurance required.]` 10 ❑ Building addition 4. I 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 do hereby cer :fy under the pains and penalties of perjury that the information provided above is true and correct. Signatu . AL'1 Date: vb.°47.3 /Phone#: ({2/ -2— PPLa -- i l 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#: