HomeMy WebLinkAboutBld-20-001135 1; ! O` I Permit#
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°"'°"`°~4 (�r� Permit expires 180 days from
L8 C.J-ab V r ;issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH OCT i. 1 201i
Yarmouth Building Department l I
1146 Route 28 C 04 South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 ?
CONSTRUCTION ADDRESS: 2. I)UN5Tr R P+)-1 H we_57 V✓-kmou M 0 02( 7J
ASSESSOR'S INFORMATION:
Map: ` Parcel:
OWNER: M14}kr( IZ F ��v 6-f 2 LiviS c ,p 4/'i^ IJ Yt„Fv t*4 9 9e 3,Y Co'f7B
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: S110"e — dN"€ OwNark
NAME MAILING ADDRESS TEL.#
yiZesidential ❑Commercial Est.Cost of Construction$ �i V d d
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
XI 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
en ura ton (Fire Retardant Certificate attached?) Wood Stove gl
ReAr-G.ENe sus /
Siding: #of Squares i0 '7- Replacement windows:# $ 4/ ✓Replacement doors: # I
ml0, 4
Roofing: #of Squares ) (p/ )Remove existing* (max.2 layers) Insulation S
VU D Old Kings Highway/Historic Dist. 5)Replacing like for like Pool fencing 0
*The debris will be disposed of at: ) 61 VatmooJ -pmi b.e.i 5, z i Ov
1 Location of Fac�{(ty
I declare under penalties of perjury that the statements re' c. 'fled 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 my l',s and f . e•eeution under M.G.L.Ch.268,Section 1.
g Applicant's Signature: / 7 f Date: 1 0 I i'I
Owners Signature(or attachmen Ale4 Date: i/O —I!
Approved By: Y Date: 10' \\— ICI
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft. of Wetlands:
0 Yes 0 No ❑ Yes 0 No
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
^� •,� www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Murk Del yl
Address: c() i'f Cyr. A-Gfo M O 7Z..o
City/State/Zip: Phone #: 9-7e g Jti -(, 7 C3
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 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.am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
4.❑ myProPertY•I am a homeowner and will be hiring contractors to conduct all work on I will I O ❑ Building addition
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.D I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp. insurance.:
6.❑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 Ail must also fill out the section below showing their workers'compensation policy information.
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 4 or Self-ins. Lic. 4: 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 certi n• 'r the rains aid penalties of perjury that the information provided above is true and correct.
Signature: Date: /O —/l — 7r)!°
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. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone 4: