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HomeMy WebLinkAboutBLD-23-000866 �,-'' •YRri Office Use Only • R E C�E V E 0 Permit# /� h�� O . !Amount 6'd W . l(e1 1 2 fn�//ATTACH fSE 1 AUG � U22Permit expires 180 days from ;issue date BUILDING DEPARTMENT &I`-23 /�)&-(0,l!j By:_ .J �.CJ�� EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)�3798-2231 Ext. 1261 CONSTRUCTION ADDRESS: S D a+C 2. Fr YeA r ro, ASSESSOR'S INFORMATION: Map: Parcel: �s DOWNER: I 1 LkC�) SZ5 I�GYv S 3 l li v►V- O©eZ Vat cv1'L Poc 1 �j Gr{ 5 �7` C700 NAME 11-64 PRR„ESENT ADDDRESS /� ®_1TEL. /CONTRACTOR: MO/n S l�t IVve� /J1(�./CL''Ck Rd YGj,-r� 617 G 6S-- F/7 lV NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est. Cost of Construction VP/ 0, /0-- Home Improvement Contractor Lic.# Construction Supervisor Lic.# 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 "rerr7P 0 n y U v7 ZW 'Z. D/5,G•9- / *The debris will be disposed of at: 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) twill be just cause for denial or re cation of my license r prosecutio• der M.G.L.Ch.268,Section 1. �b n ./ Applicant's Signature: ` � Date: d� /�,p i0wners Signat e(or a chment) /�� `y J,� ,��(e_r".„." Date: <Fi J Cl TZ Approved By: .���� �— Date: Z� Building.' cial or d i EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: • ❑ Yes ❑ No ❑ Yes U No JiQ_ 2C 22 The Commonwealth of Massachusetts WONT Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia MP 4 \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): .fAjnrn a S tJ - A'4')vl i, Address: gitau> /.-�lvP- iQoc,,k Rd, City/State/Zip: co/n.104-74, Phone #: 6r7 - 6 oc — 3'3 I'? Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself 9. El Demolition ❑ y [No workers'comp. insurance required.] 10 0 Building addition 4.0I 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 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.124e are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other /e,r 00tdOor 152,§1(4),and we have no employees. [No workers'comp.insurance required.] `SpJ44, *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 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 perjury that the information provided above is true and correct. lgnature: 7 Date: 0 Phone#: 6i?-- 606 Offcial 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 5. Plumbing Inspector 6. Other Contact Person: Phone#: or ;ter. ,. . Oriir ) a . r