BLD-23-001438 2 01•Y` 4 �,�11 Office Use Only
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, II�Il� ' H / /l>/ ' RECEIVED !Permit# 'l
�` .arc Esc,} _..___._._.._...._._� Amount/ D V
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`== ' ="" SEP 1 4 2022 Permit expires 180 days from
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BUILDING DEPARTMENT
EXPRESS BUILDING PE ' ---
TOWN OF YARMOUTH 1314) -029
Yarmouth Building Department d�r���
{ 1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 2 Z9Tj®4 5 /4-0 ' � A P.G .7
ASSESSOR'S INFORMATION: ® �
Map: Parcel:
OWNER: � -✓/r/Sl�✓N i ./V.� 51Arli yAf� ,j Y/tP� lien ✓ '"
Gf/ —4/'8- V
NAME PRESENT'ADDRESS / TEL. #
CONTRACTOR: lAii 177 r
N MAILING ADDRESS TEL.#
residential 0 Commercial g04.
Est.Cost of Construction$ ¢/5240
Home Improvement Contractor Lic.# 6 7 'i-�----.
Construction Supervisor Lie.#
Wor Compere ion Insure: (check one)
II am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
ame: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# C)
Replacement doors: #
S1 oofing: #of Squares 3 ( )Remove existing* (max.2 layers)
Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: Yj 2111 ag 7 ' -P447
j LdEation 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 revo f my 1. and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature:
Date: "77^
Owners Signature(or attachment)
Date:I- iIIIIII
2
Approved By: Building Officies .— '
( g EMAIL ADDRESS:/J
Zoning Diict: '/
Historical District: 0 Yes e No Flood Plain Zone: 0 Yes A#'No
Water Resource Protectio i District: Within 100 ft.of Weti ds:
0 Yes Nno 0 Yes P' No
• \
The Commonwealth of Massachusetts
_; 1=r Department of Industrial Accidents
i i
'" I 1 Congress Street, Suite 100
Boston, MA 02114-2017
\tti:..._,,› _ www.mass.go v/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Lezibly
Name (Business/Organization/Individual): ✓.arl-//1
Address: / ,3 % Tit'Xi
City/State/Zip: ' ,/ '2117 --5—,*"Phone #: - ` -1
Are you an employer?Chec the appropriate box:
Type of project(required):
1.11 I am a employer with employees(full and/or part-time).* —
2.0 I am a sole proprietor or partnership and have no employees working for me in 7. — New construction
any capacity. [No workers'comp. insurance required.] 8• [✓Remodeling
—
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.] 9 — Demolition
4.Iam a homeowner and will be hiring contractors to conduct all work on my property. I will 10 7 Building addition
ensure that all contractors either have workers'compensation insurance orare sole
proprietors with no employees. l l. Electrical repairs or additions
12.E Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp. insurance.x I3•[. oof repairs
6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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:
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 and t pai d fperjury o penalties that the information provided abov is tr e'and correct.
p
Signature: � , ,,
Date: ,%V ,702-7--
Phone#: GTj 72 —
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one): Permit/License#
1. Board of Health 2. Building
6. Other b Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
Contact Person:
Phone#: