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Home My WebLink AboutBLD-23-006010 N,,.,OF;YaR C n /J/ .I Office Use Only ' OC 6-1Z I Permittk O . _,-3: Amount ,'r0.00 Vu MATihcn CSC ' I Permit expires 180 days from `':fir '. !issue date 5Li- a3 -MI/0JO EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 MAY 012023 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 7 ,Z3re vr/S f-e r 7ry• W Y Q 1'44 o t1-I 4 4 N i Gf Z 7 3 ASSESSOR'S INFORMATION: �1/ea S e Map: Parcel: �' We- c 22 Ce //- /7 A-P /6/‘6 tr OWNER: �1 L!,$'0 kj Al �C'o/ e s 0. U re v),5k' ,e0/ yak,44,,IM /a cc,,/ 3-6,3) 77.5- /3 9/ NAME PRESENT ADDRESS TEL. . CONTRACTOR: f NAME MAILING ADDRESS TEL.# F�Residential 0 Commercial Est.Cost of Construction$ /DO On OD Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm Compensation Insurance: (check one) it I am the homeowner 0 I am the sole proprietor 0 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: # 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: (,(,voi O t,tiA du ht Locafion 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)",4 Date: `f-�02 3 Approved By: 4:722 Date: C..) •-/2 3 Building Official(or design EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No '''� The Commonwealth of Massachusetts '* t + Department of Industrial Accidents Mw- 1 Congress Street, Suite 100 Boston, MA 02114-2017 5.•1 www.mass.gov/dia IMPWorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Sus a.,4 /-1 Sco /Ie S /Address: y �Yecvs mac/ City/State/Zip: j, yavrvi ou/A /',2 Phone #: C G/7 e/ >416 0 Are you an employer?Check the appropriate box: Type of project(required): l.❑ 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 3.Iaan capacity.[No workers'comp. insurance required.] am a homeowner doing all work myself. [No workers'comp. insurance required.] 9. [ Demolition 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 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑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.t 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 certify under the pains and penalties of perjury that the information provided above is true and correct. ✓Siana • Mill 2 / oZD A Date: 0 Phone#: - ' CAL 6 /7 ,Z g/ Re‘d 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#: