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HomeMy WebLinkAboutBLD-23-001063 • � 'Y` t�9R L h/k (Permit# etAtipUse Only h • fr 004 1. !(�. I.1lg _ y 'Amount s(/.110 G • MA 1A�H ESE CS)a �,oa.�«o"° �d !Permit expires 180 days from issue date /3 — 023-661de'3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 AUG 2 6 2022 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: e76 // E e �� � /f� By —_ ASSESSOR'S INFORMATION: Map: Parcel:OWNER: �. / lirlc�'_ �j�7!fC!?v e/C/� ,c`�/�c�,�/' .J �3 9y�d�� NAME PRESENT ADDRESS / TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# n fesidential ❑Commercial Est.Cost of Construction$ &O M.Oa Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) L9�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 Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #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: >7 1r 4/ 61A ' ) -t 4 f ki J 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 ' ense and for prosecution under M.G.L.C 268,Section 1. b Applicant's Si ature,727 �;� - Date: e: /o.7 9! Owners Signature(or attachment !/�.� �. �Lr 6 -Z Date: O G/7 Approved By: ( Date: O © - Building O icial(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes D. No The Commonwealth of Massachusetts 1C L Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 \t'ir 61 www.mass.gov/dia No Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): j>/���_/,,,,, 7 '/:,=,--'c--",,,:,,,,- Address: / /- e> / C..,-,,.- City/State/Zip, - , X,7 j% es,;W(/ Phone #: e,;? y / /'G Are you an employer?Check the appropriate box: Type of project(required): 1.E1 I am a employer with employees(full and/or part-time).* 7. New construction 2.❑I am 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.— 10 ❑ Building additionam a homeowner doing all work myself. [No workers'comp. insurance required.]t 4. I 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 sale 11.❑ Electrical repairs or additions proprietors with no employees. - 12.❑Plumbing repairs or additions 5.E1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. 00f 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.Q 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. Signature: . / ,�-2� 7 Date: �2 7.2_ - 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#: