HomeMy WebLinkAboutBLD-23-000870 •YgR. `�Office Use Only
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EXPRESS BUILDING PERMIT APPLICAT I Iv E D E I V E D
TOWN OF YARMOUTH -''-
Yarmouth Building Department FAUG 1 7 2022
1146 Route 28
South Yarmouth, MA 02664 BUI al yd AHTMENT
(508) 398-2231 Ext. 1261 By: ig
CONSTRUCTION ADDRESS: a S LOti-1 Pbi1Cif
ASSESSOR'S INFORMATION:
Map: Parcel:
I OWNER: L27.cie4e, AU2lJer r .97,1- L e�U �J U, . !13 u77' 1j3 fl r/
N PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction$ 7,s
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman Compensation Insurance: (check one)
VI'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: # D Replacement doors: # I
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:
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:
✓Owners Signature(or attachments ::::.:
�G'
Building Official(or designee) L ADDRESS:
/
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: •Within 100 ft.of Wetlands:
❑ Yes 0 No ❑ Yes �❑ No
•
The Commonwealth of Massachusetts
mowerDepartment of Industrial Accidents
f- � 1 Congress Street, Suite 100
G Si = Boston, MA 02114-2017
www.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
u Name (Business/Organization/Individual): 07 2i pv
Address: ��,r !°�� �� � ��vUu Vof44-o6- ftj4. ` ) y
•
V City/State/Zip:
Phone #:
Are you an employer?Check the appropriate box:
1. I 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 8. ❑Rem delinruction
any capacity.[No workers'comp.insurance required.] • Remodeling
3.�am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition
• ensure that all contractors either have workers'compensation insurance or are sole
11.El repairs or additions
proprietors with no employees.
5.0 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.$ 1 •Q Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14•❑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 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:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the pol cy 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.
IIl do hereby certify under the ains and penalties of perjury that the information provided above is true'and correct.
✓Signature:
Date: 2 2-
Phone#:
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. EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#: