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Home My WebLink AboutBLD-23-000533 • ' ��I� (Ct �� KJ Y`Pi l� -e co? Office Use Only � ' �� w rl I i A F,.. a"e Permit#C/1tr►, 1ll� L.„ ,,,. n� gJ � 0 �- y .�,:0' Amount 5Q,ob k- 4. ��no.. S c• Permit expires 180 days from issue date B1.1D— 2.3 -6665 3 EXPRESS BUILDING PERMIT APPLICATICET C E I V E D TOWN OF YARMOUTH (-� Yarmouth Building Department [ AUG 01 2022 1146 Route 28 South Yarmouth, MA 02664 Buite P r er (508) 398-2231 Ext. 1261 - °y CONSTRUCTION ADDRESS: ii• K A l G a t S t`V Fvi ASSESSOR'S INFORMATION: Map: 6 6 Parcel: /6 OWNER: M. 1 C:i'.CA.t 1 1 6 2C-C. 9 i<Al C, GS L.•)kf 7 7 V - 72Z -32Z/ NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential ❑Commercial Est.Cost of Construction$ V V 0 O r Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman' ..compensation Insurance: (check one) Vain the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent n Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# 6 Replacement doors: # Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation El I I Old Kings Highway/Historic Dist. placing like for like Pool fencing n *The debris will be disposed of at: ,�ex v O c..,.4(" ( 6 S c e--N- , 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 or revocation of my license nun er . . .Car.268,Section 1. > Applicant's Signature: / Date: 6—j r 27 Owners Signature(or attachment Date: &/i 2 Approved By: ,!/a/.. ..„— _____ Date: g:2-2_Z Building Offi cial(or desi /// 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 No `OF YAk A message from the k ` 0 tot. F y yarmouth Water Department „ ,ay cy 99 Buck Island Road• West Yarmouth, MA 02673 •508-771-7921 ATTENTION HOME OWNERS AND CONTRACTORS!! Please note that the box shown below is property of the Yarmouth Water Department and is an important part of the drinking water metering system. The Yarmouth Water Department utilizes these "End Points" to collect water usage readings from our customer's water meters. PLEASE DO NOT REMOVE THEM FROM YOUR HOME OR BUSINESS!! If work is being done in the vicinity of the End Point, please take care to maintain the wiring and securely reinstall the End Point. If the End Point is damaged or lost, or the wires are broken, the Water Department will charge the property owner for any necessary labor and equipment needed to make the repairs. Please call the Water Department at 508-771-7921 with any questions or to schedule a repair. Thank you for your assistance in keeping our water system running smoothly! tirkt THANK YOU FOR YOUR HELP! w.= For more information visit: ., � www.yarmouth.ma.us/139/Water ; yay N —:.'p ' • 4Y 1 dry Yj ff. • • • r. . r R The Commonwealth of Massachusetts ► _* fl Department of Industrial Accidents =a= 1 Congress Street, Suite 100 _,14_= Boston, MA 02114-2017 = wwx.mass.gov/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): iC L ce (( � Address: (--( LC(A/ (,t{ C-v0t7 City/State/Zip: Lie-6)_ Phone#: 7 -7 &( Are you an employer?Check the appropriate box: Type of project(required): LEI am a employer with employees(full and/or part-time).* 7. ❑New construction 2 a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp-insurance required.]t 10 Q 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 I l,Q 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. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. 1Contractors 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 of perjury that the information provided above is true and correct. Si nature: Date: z Z-- Phone#: 7 - 1 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: