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$�,,g,(�! 0 I Permit# O' �
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;Permit expires 180 days from
issue date
CIEIV
EXPRESS BUILDING PERMIT APPLICA _ E D
TOWN OF YARMOUTH APR 21 2022
Yarmouth Building Department
1146 Route 28 -
South Yarmouth, MA 02664 B y. Ng)rp sty,IENT
a?,53 i- (508) 398-2231 Ext. 1261
`5
CONSTRUCTION ADDRESS: a 5 v IC. O-Or\hOJS. Q, 5L1) -- " j DI1)I
ASSESSOR'S INFORMATION:
pp . Map: Parcel:
OWNER: f-L . f1(� �.�(l AI' OtD AM 4ocA .;
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction$ 7 000, l-7D
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workmompensation Insurance: (check one)
I 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:# 7 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: t(L LJ(( _AA 1� t.Ar(- )
l` Location of Paoty
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 rev ion m�license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: /I`` "-"--- /Date: - 0/ '' C .
v /
Owners Signature(or attachment) / `'' Date:
Approved By: ,., ii Date: 4. 'r 2' '""A-2.-
Building Official(or d-.. nee , EMAI rDRE;r.
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
The Commonwealth of Massachusetts
a—;� ►= Department of Industrial Accidents
`:rr� 1 Congress Street, Suite 100
_1Jf
_ Boston, MA 02114-2017
'� www mass.gov/dia
\Vol-kers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information
Name (Business/Organization/Individual): �- Please Print LegibI
l�r, IL �i4
Address: .? Li e-- -1 0
City/State/Zip: ,� �
Phone #: - ' _
Are you an employer?Check the appropriate box:
LIDI am a employer with Type of project(required):
employees(full and/or part-time).*
2.0 I am a sole proprietor or partnership and have no employees working for me in 7. ❑R New Construction
any capacity.[No workers'comp.insurance required.] 8. Remodeling
3.I am a homeowner doing all work myself. [No workers'comp.insurance required.]t
9. emolition
4:0 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. 11.Q Electrical repairs or additions
5.�I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
12.[]Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.$
13.0 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14.Q 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
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating
:Contractors 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,they such.
must provide their workers'comp,policy number. es have
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job sit
information.
e
Insurance Company Name:
Policy#or Self-ins.Lic. #:
Expiration Date:
Job Site Address:
City/SAttach a copy of the workers' compensation policy declaration page(showing thetpol policy
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable b e a finer
p o•
$1,5 date).
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER Y up up o$250.00
day against the violator. A copyand a fine of to$250.00 a
coverage of this statement may be forwarded to the Office of Investigations of the DIA for insurance
rase verification.
I do hereby certify and the pains and penalties of perjury that the information provided above is true'
�gnature: i and correct.
Phone#: Date: 'cQ( _ cG
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority(circle one): Permit/License#
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing
6. Other nb Inspector
Contact Person:
Phone#: