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Home My WebLink AboutBLD-23-00880 O� `�R 1 ice Use Only +� ,;� ��,� Permr 3_ !Amount MATTACn CSF FNO��Ita hp r' 1 Permit expires 180 days from -' !issue date EXPRESS BUILDING PERMIT APPLICAT , TOWN OF YARMOUTH C E 1 Y E Yarmouth Building Department 1 r.a � 1146 Route 28 I AUG172022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS:_I 0 T \51—d 7 ts..f�� C71))2 1`Z ASSESSOR'S INFORMATION: Map: Parcel: �/� )� / _ —1'74- O WNER: ✓ !- 1 A T/ N �0 �) n{ Y� - L Yet c �4 "9 670 c 1 7$1 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ a.(10-.00 ✓ Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation 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: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing te1.1c' .$Xr�� :y�*The debris will be disposed of at:T*t"....n f�0.6-L:leo* `"1.,+ - - ) L co--)e) Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial :vocation of my licen e and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: Oat) 7 Owners Signature(or attachment) Date: Q 11 Approved By: Date: p` � ' d6•- Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes E No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No I The Commonwealth of•11Massachu sett s ' i = Department oflndustrialAccidents a-:r_i_^ 1 Congress Street, Suite 100 Boston, MA 02114-2017 " www mass.;ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Name (Business/Organization/Individual): fr Please Print LeQib[ Address: ® .6 it- City/State/Zip. jr.t, '2 - 17$ L b 1 Phone #: c' .4 _q 0 1 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).* 7. 2.0 I am a sole proprietor or partnership and have no employees working for me in ❑New construction any capacity. [No workers'comp.insurance required.] 8. El 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 n Building addition proprietors with no employees. 11.0 Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and haveinsurance.: 12.0 Plumbing repairs or additions 13. Roof repairs workers'comp. 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.E 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 f 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 have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number, such. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and information. P Y 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(showing the ao policy number Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable b a fin expiration$1,500.00date). and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDERy fine up upo $25 day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the e of to insurance a coverage verification. DIA for insurance I do hereby certify under the pains and penalties of perjury that the information provided above is tru Signature: "-L,,..� e and correct. Phone#: 3 Date: O $- '-)-'�tj2-� C-� G � 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. ectrical Inspector 5. 6. OtherPlumbing Inspector Contact Person: Phone#: