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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH �_
Yarmouth Building Department IRECFAVED
1146 Route 28
South Yarmouth, MA 02664 SEPQ2Z
(508) 398-2231 Ext. 1261 r
�9 BUT-DING DING DEPARTMENT
CONSTRUCTION ADDRESS: ¢/ / 4CiTE�Z/L ✓em d By _
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ASSESSOR'S INFORMATION:
Map:aSr Parcel:d; 3if j
OWNER: TACO ligL)/yam Alit'0/f4.441/
NAME
r�hh PRESENT ADDRESS TEL. #
CONTRACTOR: /c4,el &-1ti77 //Lv 06 £Fi?Ilt/6G:R , lPE 6/ ,ol'd5 kNO- ("1:‘‘‘.
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction$ 5'' 7do�"
Home Improvement Contractor Lic.# /®(c/3 f Construction Supervisor Lic.# QEAa 9'673
Workman's Compensation Insurance:check one)
❑ I am the homeowner K 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 Replacement windows: # Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max. 2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
REPL gee DECKir-'6 trili 1d'x/7- 46. /1T/44- vrCA- /Ir►/0RP77/4ce .Fxlfr1,06- .2/914c
ri,Tb' r/2ADt'M,Vz/i Rt4/4 C
it(�V*The debris will be disposed of at: %i 7
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.
9
Applicant's Signature: iitAA
4C.(iltiG � Date:
. I Date: (-1)—
Owners Signature(or attachment)
Approved By: oZ
Date: -- - Lt—
Building Official es e) EMAIL ADD
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
Commonwealth °at onal L censure
. -. Division of Occup
Board of Building Regions and Standards
gr,Isor
* Cons "t` 1.
CS
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4111i,pires':0210612024
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GILBERT M t I `
25 KENSING N ` i► ; ; k°
WEST N ` < i' /mow ,� I�
.., '' 37 1. ? ;,tip .
Commissioner 4
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Aff , &Business Regulation
HOME IMPROVE ,i;,4 ONTRACTOR r
R_, ., 1RaL •.n
4; : Aii.e l st e i
GIULIO REALTY TR "'fi`•
',:-'''W" 4,..S,7A,s, .
GILBERT M.MARIANI R
25 KENSINGTON AVE
WEST NEWTON,MA 02ft..
„.)''' Undersecretary
•
•
•
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The Commonwealth of Massachusetts
_*Sir_ 1, Department of Industrial Accidents
1 Misl- 1 Congress Street, Suite 100
`_ Boston, MA 02114-2017
5�,'P 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): 6-1/4,./‘/e9/etAt/Ty 7 111 r
Address: v1(o -SPRillia-ER z ex/4
City/State/Zip: l�ecTY/// Af't'T/f Phone #: et icj a'f' ?, J'1pS'4"
Are you an employer?Check the appropriate box: Type of project(required):
LE I a a employer with employees(full and/or part-time).* 7. El New construction
2 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
` 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
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-contractprs have employees and have workers'comp.insurance.t
I4.,[]'Uther p1 Ck/2FP,I9//AS
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
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.
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Signature:,r��f� t��:/�/069iL�L Date:�/
Phone#: 6 i?-r oiti5-1 521.4 - rp I L — L1-1),_?-2/` asyd'
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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#:
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