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Home My WebLink AboutBLD-22-007219 O� RR 6 a ,�, 0 1 111 Office Use Only vim" //�,c e O j . ... Permit# (,�,.A `7 r tA x jAmount 56 zi0 MATT, ,, , d :, *w•a�,�o»�c Permit expires 180 days from j issue date 13t/D —02,,2 0 701-/q EXPRESS BUILDIN G PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 JUN 14 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 G_DEPARTMENT /J� BY CONSTRUCTION ADDRESS: £t'; /� Y 61y l 4'z l ) A/✓k" m %, "7 s ASSESSOR'S INFORMATION: /'l� Map: Parcel: OWNER: 1 I ill C�U[ Mr is W 7 _� / e Z e ' 7 1 - 16 ZY) 7 D 7 - -3 3-J D NAME PRESENT ADDRESS TEL. # � CONTRACTOR: 66}5)/.1 fo -7 Doi 1 41 C6 Sd_4r d>G tit) <. MAILING ADDRESS TEL.# ��Z J �s ':p!•esidential ❑Commercial , Est.Cost of Construction$ '7 4D d c v� Home Improvement Contractor Lic.# I Li I ' 14 b Construction Supervisor Lic.# C s 6 1''L5j L 1' Workman's Compensation Insurance: (check one) ❑ I am the homeowner %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:# q 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: 6 D IA ✓ (j,L4 ( 1 l 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: Li i i /Z Z c i Owners Signature(or atta ) Date: Approved By: �/j // _ Date: 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 0 No I ��= t • The Commonwealth of Massachusetts _'.r4,*= Department of Industrial Accidents 1EST ,�_ e— 1 Congress Street, Suite 100 ='�`= Boston, MA 02114-2017 :•5 www.mass.aov/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 4" t 1 -� Address: /4 . 7.7 City/State/Zip: ' MI- OU.li Phone • ) ) Are you an employer?Check the appropriate box: I am a employer with Type of project(required): 1. ❑ employees(full and/or part-time).* 2.G3 I am a sole proprietor or partnership and have no employees working for me in 7. ❑New construction any capacity.[No workers'comp.insurance required.] $• Remodeling ` 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.] 9. !J Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition 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. 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 MGL c. 14.El 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. 1.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: 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 corr ect S ionature: Phone#: Date: G 7 z-� 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 6. Other P 5. Plumbing Inspector Contact Person: Phone#: Iii!Iln of . .x • • LL Iv '.. ._err. Sal_COMBO _ 8: • DMA ,, J.COFIQRO ‘, tJA ,�gam- v, . FOFESTDALF,Moo ®�.. -"Ty , ' ry •« .�-COOMOMIMOIM of i1�Wsc , --- a Division of Occupational Lic�, 'c " Board of Building it uiations and Standards . . . Cans isor �' �I ,CS-082529 aV * pices: 12/10/2023 , TIA • • .j FORESTDALt x ,14 • ?p 3' .,j • • • •