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Home My WebLink AboutBLD-23-005856 C'..x�R :1 Office Use Only 0 r3Permit# gQg 0 C 1-3 ttATTA M ESEJ"� IArnount O,J' gD ta '4Po.rtuap e I Permit expires 180 days from 1 issue date 3tD -023 -065g5f EXPRESS BUILDING PERMIT APPLICAT r F ' V c D TOWN OF YARMOUTH .. , Yarmouth Building Department 1146 Route 28 1 r APR 20 2023 South Yarmouth, MA 02664 ; L (508) 398-2231 Ext. 1261 au+�°�"� UtPARTMENT %. CONSTRUCTION ADDRESS: 5 YOr 1 O v1A d O a 67 - ASSESSOR'S INFORMATION: /� j �`' Map: Parcel: OWNER: b47 NAME/tAcij ni 15 /t4i r)n c 114'( m ) YnrA4/ 1 508 - 36.0 J 1/ PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est. Cost of Construction$ ad 400,0D Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) Pi'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 'e Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation V Old Kings Highway/Historic Dist. V)/ (,�y� � ( Replacing like for like`s/L�Pool fencing 0 t.. dAi., 4.1,44,i, L-01 4y1-1\i *The debris will be disposed of at: i OLV V% Mikv/dii I) D , . , 5p0, I ,..(,_,,, ocation 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 attachment) / Date: 7/1/c90(q2 Approved By: './1"/' c 2� � Date: Building r ' (or designee) EMAIL ADDRESS: -R-y kuj(D�C(),n�-e,elc'� Mgr Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No -� .' , \ The Commonwealth of Massachusetts r ^ , Department of Industrial Accidents 1 Congress Street, Suite 100 ear,\ , Boston, MA 02114-2017 it so. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): -Tor C� 341 r l I Address: ,/4ih vie�t,>Cf .t 1.di f1 �J DI City/State/Zip: OD,6 7 Ph ne #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑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.] 3.0 I a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp.insurance required.] 4. I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 ❑ Building addition . ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑ Electrical repairs or additions proprietors with no employees. - 12.7 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.: 1 •Di Roof repairs 6.0 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. 1.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 certify u r the pains a penalties of perjury that the information provided above is true'an correct. Signature: i, I/b 6 a � Date: / Zj 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#: