The URL can be used to link to this page

Home My WebLink AboutBLD-23-001603 "�. Office Use Only . 4. .Y e 4 I G'I A GJ1Z3L o R, ?J'Z • I Permit# 0 i,'4 . y jAmouqiaD -'� MATiACN LS[ �' \•.,e„0*.°E-,d.' I Permit expires 180 days from :*,',- l issue date 8th a3-ao 1403 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECE1 ® Yarmouth Building Department 1146 Route 28 1 fr South Yarmouth, MA 02664 SEP 2 3 2022 (508) 398-2231 Ext. 1261 1 U BUILDING DEPARTMENT CONSTRUCTION ADDRESS: G2 L a v Ai e f 1 G it/e �' ( �R M°v T �} BY: ASSESSOR'S INFORMATION: I Map: Parcel: , -OWNER: Pl1.71,P V. M�s5 ,2 La& R�'r5' IgA✓C Irog, °`1 5 o � 2 � 17 ,a NAME PRESENT ADDRESS TEL. # CONTRACTOR: _ ___ _ NAME MAILING ADDRESS TEL.# �^ coo,e,el ®-Residential 0 Commercial Est.Cost of Construction$ S,UU4£io 7 L.----- Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) hl.-Yam 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 ,boo St IT //' Replacement windows:# 7 p .../ Replacement doors: # 3 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (KReplacing like for like Pool fencing *The debris will be disposed of at: - 14'kr u Q17 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 attachment) 1'� nri �4 Date: 9-A'Zr ✓ Approved By: 6 ' Date: � 7��.v., Building Official(o sig EMAIL AD►•fS: I iti 'tvotd vpt 4y 0 co ,7(4 s f , I✓{7' Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No '� .. 1% . The Commonwealth of Massachusetts ' 1=4614iiiii"-- r Department of Industrial Accidents 1 Congress Street, Suite 100 C-°r►= Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information Please Print Legibly t/Name (Business/Organization/Individual): P I/;11; P 4.4 170 S S •-Zj t/Address: ,2 14v A,' r c 14 A'-1- City/State/Zip: :, Ya P t°vrN l /14, 026i4 Phone #: 3 0 8'- .), l - /7 4 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. I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling an capacity.[No workers'comp. insurance required.] ` 3. am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 10 ❑ Building addition 4.E1 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs yap�.5� Pao I These sub-contractors have employees and have workers'comp. insurance.t Or pit e .if, 4/ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther 4- S%de,^/) 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. ✓gnature: i—J, fir. 001.4..v. mate: q-, - . 2 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#: f . •, I t ♦ ` • • • •♦ - ♦ •