The URL can be used to link to this page

Home My WebLink AboutBLD-23-001294 ;.0-:.Y44i-- W -6( q 1 12,1 z� Office Use pOnly y� a r $ v' Permit# V�{.s�'i 3 ' 0 y; ;Amount qUll •-••' MATTA M CSE „'1 ,�oopatO ,,e Permit expires 180 days from {issue date 6LD f 3 —0 OVIII EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 SEP O 9 ZQZ? (508) 398-2231 Ext. 1261 BUILDING DEPART CONSTRUCTION ADDRESS: e 1 -Pp` " By MENT ASSESSOR'S INFORMATION: / Map: '� j „ Parcel: 3- OWNER: h1CL( -t. S L' /----r l n / ew,4 op,047 5- g /.3 7 V c/ ') NAME PRESET #ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential ❑Commercial Est. Cost of Construction$ '/ OO .. 0 6 Home Improvement Contractor Lic.# Construction Supervisor Lic.# ` Workm�an�' ompensation Insurance: (check one) kY l 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 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: 2 o 0 Cs ,d- k/ L,s /�""(r',r Z 4. ,So, T ,r.4r 5' ro Location of Facility ` / �CJ'C G'/ V J-/c 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 oror revocation�a(� of my J I qmy license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 1 44-11 Date: 7— / - a-O al-. Owners Signature(or attachment) Date: 9 _ -1 - .0 a-a. Approved By: Date: �r/2 '2/l Building Offi ' (or b EMAIL AD S: 1r\,t-\ •e,•-t h 1 i S-S`Q_ in o i-l4.1 a i' Li C 0 jii . Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes U No be4,1 0 GLiA4 ikep f PR Pet 1--- CiJa L Y / • The Common wealth of Massachusetts o Department of Industrial Accidents - 1 Congress Street, Suite 100 "1'`' Boston, MA 02114-2017 • www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Name (Business/Organization/Individual): Please Print LeQibl Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: 1 Type of project(required): .0 I am a employer with employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. ❑New construction a capacity.[No workers'comp.insurance required.] 8. R odeling 3. I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 9. al Demolition 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 10 El Building addition proprietors with no employees. - 11.El Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contactors listed on the attached sheet. These sub-contractors have employees and have workers'comp. ins 12.El Plumbing repairs or additions 13.❑Roof repairs insurance.t 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. 14.❑Other [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' tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities employees. If the sub-contractors have employees,theyindicating such must provide their workers'comp.policy number. have I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. p cy and job site Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workers' compensation policy declaration page show'CQty/State/Zip: the Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation pcy umber and expiration date). and/or one-year imprisonment, as well as civil penalties in the form of a STOP WO day against the violator. A copy of this statement may be forwarded to the punishable by a fine up to$1,500.00 WORK ORDER and a fine of up to insurance a coverage verification. Office of Investigations of the DIA for insurance I do hereby certzfy under the pains and penalties o perjury that the information n provided above is true'and correct Signature: A , 1 n ) qPhone#: SO g- 73 y Lis 1 � Date: o� O �-� Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Author- i Permit/License# I. Board of Health (c'rcle one): Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing 6. Other mbmb Inspector Contact Person: Phone#: "Ir