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$Or TOWN OF YA OUT AIK 1N U. .
LDING DEPA ENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
ov-o- 1{)i
APPLI
CATION FOR CERTIFICATE OF INSPECTION L \�
June 1, 2023 PAYABLE UPON RECEIPT
(X) Fee Required$100.00
( ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a
Certificate of Inspection for the below-named premises located at the following address:
oI,
Street and Number: a ko w( O r 1
Name of Premises: V(�-e'6 1 lv N Nee Co Tel: ,�o d 3612. 3 ( D 2
Purpose for which permit is used: L D6' 1 W U
License(s) or Permit(s)required for the premises by other governmental agencies:
ED
License or Permit R. E C EIV
Agency
SUN ' 4 iFo]gDE=1' RI-MEN
LLIi
"�... Certificate to be issued to \I 1 LL A 1 s\ ( �'Q n Tel: , O� 3E 3 i O
Address: S ‘
Owner of Record of Building Cl-1/ 11
Address e
Present Holder of Ce 'ficate cL.AAi
oAie4--
Signature of pers n t Title
Certificate is issued o is ent 6/ d 11/ ZZ3
Ji ,kó-.I
Date /r
Email Address: 1 Aid.', ‘C 4 .yvt ,qtc • 6
Instructions: Make check payable to: Town of Yarmouth
1146 Route 28, South Yarmouth, MA 02664
Return this application to: Building Inspector's Office
Please note: Application form with accompanying fee must be submitted for each building or structure or part
thereof to be certified. Application must be received before the certificate will be issued. The building official shall
be notified within ten(10) days of any change in the above information.
PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS
APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# /j(',aa-3__ j 7
07/16/2023-07/16/2024 /
g==. • The Commonwealth of Massachusetts
/
Department of lndzistrial.Accidettts
.
1 Congress St
reet,tree_
Boston, MA 02114-2017
umwww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information
Name (Business/Organization/Individual): M Please Print Le ibl
Address: 7t
City/State/Zip:---- �� ,t}(�
ki2k Phone #:_ b d , � _ `s 1. z
Are you an employer?Check the appropriate box:
1.0 I am a employer with employees(full and/or part-time).* Type of project(required):
7.
2.Er1 am a sole proprietor or partnership and have no employees working for me in ❑New construction
any capacity.[No workers'comp. insurance required.]
s• 0 Remodeling
3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. [' 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 ❑ Building addition
proprietors with no employees. 1 I.❑ Electrical repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 2'❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.! 13.❑Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MfGL c. ❑
152,§1(4),and we have no employees.[No workers'comp. insurance required.] 1 Other
*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
1Contractors 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. lithe sub-contractors have employees,they must provide their workers'corn such.
I am an employer that is providing P P•policy number.
P 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:
Attach a copy of the workers' compensation policy declaration page(showing thetate policy number and expiration date
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine upto$1 500 )
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of p to$250.00
day against the violator. A copy of this state nt may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification. 10 a
1 do hereby certify ! • the pains and pe ;l 'es o above true jperjury that the information provided is
Signature: / and correct.
ad
Phone#: Date: i l 4
IX i 2--
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Author Permit/License r
ty(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspecto r
1. Other
e
Contact Person:
Phone#: