HomeMy WebLinkAboutBLDX-23-15415-CONSTRUCTION ADDRISS:
AS SESSOR'S IITTFOfu\'lATION:
. y', .-.-(a,,t,
Office Us. Ooly
Pemit expires 180 days from
, issue date
RECEIVED
ocl 03 2023
BU IL DING DEPARTMENT
EXPRESS BUTLDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Buitding Department
I 146 Route 28
South Yarmouth , MA 02664
(508) 398-2231 Ext. 1261
Mup Parcel
or!}jER z,^,1-I -{r'r.',-. L-J,L*9 7L,!5NAr\lE P ENT DRESS
N}JVIE NL\ILNG ADDRESS TEL #
El{esidenrial I Commercial Est. Cost of Consruction $ 7, a ao
Home Improvement Contractor Lic. #Construction Supervisor Lic. #
Workman's Compensation Insurance: (check one)
Ji'am the homeowner I Iamthe sole proprietor J I have Worker's Compensation Insurance
\\ORK TO BE PERFOR\IED
Tcnt Duration (Fire Retardant Certificate atlached'l)
Siding: # of Squares \--Replacement windons: #Replacement doors: #
Roofing: # ofSquares_ (
Insurance Company Namc: Worker.s Comp. policfi--
lnsulation
_ Old Kings Highway/Historic Dist.
) Remove existing* (mar.2 layers)
( ) Replacing like for like Pool fencins
</"A;
tion of Frciliti
the statemen hercifl contained are true and conect to the best ofmv knowledge and b.lief. I ulderstand rhat any false answe(s)n ofm and for prosecution under IvI.G.L. Ch. 268. Section I
Date 3 7a>
1-*The debris wtll be disposed ofat
I declare under p€nahies o.
will bejust cause for
Applicanr's Signarure
Owuers Signature {hment)
Approved By
t?tA t LalL
Dite
Date:Building Official (or desigrree)Elvl-{JL ADDRESS
Zoning District
Historical District: a Yes _ No
\!'ater Resource Protection Districl:a Yes lNo
3i
Flood Plain Zone: - Yes __ No
Within 100 ft. of Wetlandsa Yes I No
o^"* //0.6/-)
L
CONTR*ACTOR:
Wood Stoye_
s-\
lica o a tion
Name (BusinesyorganizatioB/lnd.ividual):z'zz t c-L
The Commonwealth of Massachusetts
D ep a rtment of I n d ustrial A cc ide ntsI Congress Street, Suite 100
Boston, MA 02114-2017
\\iorkers, compensation ,.r..",.JJ#;fr,T,1{?,,Y.!;'Jar,r,,.r",s/Electricians/prumbers.
TO BE FILED WITH TIIE PER]IIITTINC .{TITHORITY.
Please rint b
Address: L L--t,
City/State/Zip:Phone #: ilf ?a,lrs
Type of project (required)
Z. I New construction
8. I Remodeling
9.
IO
ll
1?
t3
t4
Demolition
Buiiding addition
Elecu'ical repairs or additions
Plumbing repairs or additions
Roofrepairs
Other
Any applican! thar chccks box # I must aG fill out the scction bclow showing their workcrs.compcnsation policy information.Homeowncn who submit rhls affidavi! indicating they arc doing all work and then hirc ouBide cooE-actoG must submit a new affdavit indicatins suchtcontractors that chcck this box riust attachcd an additjonal shect showlng lhc oarhc of thc sub-cootrdcloG and state whethea or not tbosc cntiries haveemployels. lf L\c suEcoffhctors have cmploy ecs, thcy must prov
I am a employer witil _cmployccs (full and/or pan-dme).*
I am a sole proprietoc or paltnership and have no cmployees worldng for mc inany c.apacity. [No workers'comp. insurancc rcquired_]
3.pl arn a homeowncr doing all work hyself [No workers, comp. insurance required.] i
o E I * 1 PT":l "r and will bc hiring conE-actors !o conduc a.ll work oo my propcfiy. I wlllcnsure that all contiactors eithcr hav. workers, compcnsation uEuranc. o. _" rlt.proprictot's witi no cmployccs.
I am a gcncrd cont-actor and I havc hircd thc sub-conEactors lisrcd on ttje attachcd shccr.Thesc sub-contractgrs havc employccs and hav. *o.kcrs, "omf. i*;;l --"-- -"
Wc arc a corporado! ,nd iLs officers have excrcised the right ofexcmptjon pcrMGL c.152, gl(4), andwe har,. no employees. [No workers'comp]ins*-",lqJrii.: ---
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Arc you an .ftplolcr? Ch.ck th.pp ropriete bot
I am an employer that is
infornntio n-
Insurance Company Name:
idc lheir workqs' comp. poliry nur-nbe,
providing workers, compensation insurancefor my emptoyees. Below is the polic! andjob site
Policy # or Self-ins. Lic. #
Job Site Address
Expiration Date
Attach a copy o number and expiration date).Failure to secure covemge as required under MGL c. 152, $25A is a criminal violatiouand/or one-year rmpnsonment, as well as civil penalties in the fona of a STOp WORK ORDER and a fine of up to 5250.00 aday against the violator. A copy of this statement may be forwarded to the Of6ce of Investigations ofthe DIA for insurancecoverage verificatio
I do hereby ce
S
nd penalties of perjury that the information provided above ts true and conecL
24>7
P ne#,s
0 nol write in this area, to be completed by city or town ofJiciaL
lssuing Authority (circle one):
l. Board of Health 2. Building Department 3. City/To\yn Clerk6. Other 4, Electrical Inspector 5. plumbing Inspector
Phone #:
OfJicial use only. D
City or Town:
Corltact Person:
punishable by a fine up to $1,500.00
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