HomeMy WebLinkAboutBLDX-23-12552-c,J
Oflic. Use ODIy
Permit expires 180 davs from
issue datec
TION
CONSTRUCTION ADDRESS:t7
8-2231 Ext. 1261
Da-
EXPRESS BUILDING
(508) 39
6tEtt a/
TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth , MA 02664
t
ECEIV
JUN 0e 2023
BU ILDING DEP
=D
ARI MENI
R
ASSESSOR'S IIIFORIVLATION
Map Parcel
OWNERT
CO\TRA.CTOR
9aat la Ce 6,/ A4 27+31{3r2_
N{\TE PRESFNT ADDRESS TEL !
NAlvlE itTA.ILING ADDRESS TEL, #
Est. cost of Consrruction $ ? O OtS "Otltr Residential n Commercial
IIofie Improvcmeot Contractor Lic. # Construction Supervisor Lic. #
Workmar/Compensation Insurance: tcheck one)Vl am $e homeowner : I am the sole proprieror
Insuratrce Company Namel
I I have Worker's Cornpensation Insurance
Worker's Comp. Policy#_
\\'ORK TO BE PER-FO R\IEI)
Tent _ Duration_ (Fire Retardant Certificate attacbed?)
Siditrg; # of Squares Replacement windows: #--
( ) Remove existing* (mar.2layers),Ioofing: # of Squares
--
Old Kings Highway/Historic Dist. ( ) Replacing like for like
'The debris will be disposed ofar
Wood Stove_
Replacement doors: #_
Insulation
Pool fencing
I declare undet pena.lties ofperjury rhat the statements herein contained are tre and conect to the best olnv knowledee and belief I understand that any false ans*er(s)will bejust cause for denral or revocation ofmy llcense and for prosecution under lvl.G L. Ch. :6g. Secrion I
.A,pplicanr's Signarure:
v4waers signar$ft @r Drrt:
DaleApproved By
,nachment
Building Official (or designee)EILIJL ,ADDRESS
, Historical District:
ZoDing District
:Yes-No
Water Resowce Protection Disticta Yes i N"o
Flood Plain Zone: I Yes: No
Within 100 ft. of Wetlands
I Yes ] No
S4r f V€<tay<c+ C4oL - <o'4
t-/
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Locrtion of Facilirl-
Dale
t
The Commonwealth of Massachusetts
Departmenl of Industial Accidents
1 Congress Street, Suile 100
Boston, MA 02114-2017
\1:orkers' compensation ,...."r."l1l;frf,,t;i?rY!,tJar,r,^"."rrlElectricians./prumbers.
TO BE FILED WITH TIIE PERMITTING .4TITHORITY.
fo tion PIea L b/Nurna (BusiresyOrganizatio lndividual):J
"/Addr.rr, l? Zo Ctl-
vciry/sor"rzip,s,Phone #: ?/
applican! tbat chccks box #l must also fil I out the secrion bclow showing their workcrs' compcnsation policy informationHomco.}'rrc.s who submit this affidavir indica:ing they are doirg atl work and thcn hiE ouBid. conFacrors musr submir a ncw affidavir indrcating sucllicontractors that chcck this box must attachcd all additional shcct showing Lhc Dame ofthc sub-contractoG and state whethcr or not lhosE entities haveemployccs. If thc suucoDfactoG have cmployccs, they musr providc thcir wo.k6s' comp. policy nuhber
).! I am a employer with _employees (full and/or pan-time).*
a sole proprietor or parmership and have no cmployecs workiog for mc in
capaciry. [No workcn' comp. insurdncc requircd.]
am a homcowner doing ali work mysclf [No worken' comp. insurance required.] I
I am a horleovficr and will bc hiring contractors to conduct a.ll work on my p.opeft/. I will
ensurc that all codE-aclors eithcr havc worke6' comperEation insuranc" o, a. rol. -
proprictors .Iiti no cmployecs.
I am a teDcral contr'ac1or and I havc hircd the sub-contacrors listcd on $e attachcd sheer_
Thcse suEconEactors ha,re employeas and have workcrs'coDp. insuraicc.l
6.! We arc a corporarion ard its officers hav. cxerciscd thetr riglrt ofcxemptjon pcr MGL c
152, S l(4), and \xe harc no crnpl(ryccs. [No workcrs' cornp. insurance requirid.]
7 Iam
any.
3
4
Arr you rn cmploycr? Chcck thc ap prixt! bot:Type of project (required)
Z. ! New construction
8. f] Remodeling
9. fl Demolition
Building addition
Elecrical repairs or additioos
Plumbing repairs or additions
Roof repairs
Other
l0
ll.
12.
13.
14.
I am an emplolet thal is Ptoviding workers' compensation insurance for m1 emploltees. Below is the policlt arutjob siteinformotion-
Insurance Company Name:
Policy # or Self-ins. Lic. #:
Job Site Address: City/S*te/Zip:_Attach a copy ofthe workers' compensation policy declaration page (showirg the poti.y ou*U..
"na orpi.rtioo art.y.
Failure to secure coverage as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00aad./or one-year imprisonment, as well as civil pena.lties in the form of a STOP WoRKbRDER ani a fine oiup to $250.00 aday against the violator. A copy of this statement may be forwarded to the Office of llvestigations ofthe DL{ for insurance
coverage verification.
I do hereby
Ph e#:
e ns andpenalties of perjury thal the information provid.ed a ve is tru and conecl-
Offcial use on$. Do not wtite tn this dtea, to be completed by city or town offi.ciaL
City or Town: permiVlicense #
Issuing Authority (circle one):
1' Board of Health 2. Building Department 3. CityiTor,vn Clerk 4. Electrical Inspector 5. plumbing Inspector6. Other
Phone #:Contact Person:
Expiration Date,_