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Home My WebLink AboutBLDTR-23-002945 Te.Y� Office Use Only k.4 O R4 L%r ! ii/ '7 102_ Permit# H/q O . il',/,. , y ;Amount 9dr od t. MATTA M CSEJ� `o+....��.,'e Permit expires 180 days from issue date etD-61.3 .Op i iLts.5 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 NOV 29 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT u,/ 1 By: CONSTRUCTION ADDRESS: 3 7 7 ; (�T-e S/ -Ra ASSESSOR'S INFORMATION: �� Map: Parcel: "OWNER: nrn (/�0 'pry er, _3yr /o rjf-/ / 7F-STh 0 - 6 6 le 4 N PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# 117Residential ❑Commercial Est. Cost of Construction$ la U Y Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check lit/1 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 be%✓i0 - ler 7C%L�'-/) ,(em ire a_ it/al f...5 i l 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.Fr ( )Replacing like for like Pool fencing r'*The debris will be disposed of at: C t7SU-- 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 and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 1 Owners Sign. ire(or. achm -4..---- Date: f1 9 (1..2_ Approved B . '/ Date: // i9/2I_i Build" Offici esi EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No • 1 Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • \ The Commonwealth of Massachusetts ,_ Department of Industrial Accidents vir 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,M.;5•s, www.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): �yy t rT(7 — J Address: .3 01 City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2.D I am a sole proprietor or partnership and have no employees working for me in ay capacity. [No workers'comp.insurance required.] 8. Remodeling 3. V I am a homeowner doing all work myself. [No workers'comp. insurance required.] 9. Demolition 4.E I am a homeowner and will be hiring contractors to conduct all work on property.my I will to E Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.$ 13. Roof repairs 6_[T]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]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: 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. S ignatur l /9� Date: \ V -2- /..-.Z Phone#: l 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#: