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Home My WebLink AboutBLD-23-001080 I1Is ta__. 0 /M'7 !/t..,._1U, e(.-c- ;OfficeUseOnly Permit# Amount 5 . Da cam, Permit expires 180 days from {issue date at-0--023-600Sb EXPRESS BUILDING PERMIT APPLICATiR C E I V E D TOWN OF YARMOUTH — ----�— Yarmouth Building Department 1146 Route 28 AUG 25 2022 South Yarmouth, MA 02664 BUILDING DEPARTMENT . (508) 398-2231 Ext. 1261 By ________ VCONSTRUCTION ADDRESS: . 1.4-eltiA5vt,o, I r y i(tMioL pd•-J cM JI-- ei.-C7 i ASSESSOR'S INFORMATION: �� Map: Parcel: 2 "OWNER: 0�C.WG� v e0_t^.r ''1-7q 7 J6-5 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# f Residential ❑Commercial Est.Cost of Construction$ fO,00 L1 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workmaip Compensation Insurance: (check one) filrf I 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: # 7 , ' Replacement doors: # 1 Roofing:in #of Squares ( )Remove existing* (max. 2 layers) Insulation v Old Kings Highway/Historic Dist. (VcReplacina like for lie Pool fencing vt., 0 14.1 4\(0- 5129 a-c \/ *The debris will be disposed of at: )/f.If.L4L 61Uv...0 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: i 1‘1 Owners Signature(or attachment) p ' Date: oZZ. Approved By: Date: k--3o— Building Official(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 ❑ No --- The Commonwealth of Massachusetts f, Department of Industrial Accidents I Congress Street, Suite 100 �. I Boston, MA 02114-2017 "... _ www.mass.;ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly fame (Business/Organization/Individual): Sit i L 1 %,PA4-`( ddress: 114.Iw"-5 i..n c h rr-q City/State/Zip: y6,rww L i-1,._v90,.1"" Jim- aver r Phone #: -71 L f 36- 3 PzS/ 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.E 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._I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑ Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 n 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.1 14.❑Other lv(tnr,rw.j� rD i c, Fr, M 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees. [No workers'comp. insurance required.] 1 �G�-;✓l S dC-r *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 certi der pains and penalties of perjury that the information provided above is true and correct. /Signatire: Date: "kb-5. /2 Z 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 1/14 f1A-el Cir / / y re /KCA L I� &A ddLDS j sft��f re H-cc! 1 fi r'