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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28 OCT 18 2022
South Yarmouth, MA 02664
508 398-2231 Ext. 1261 ______ _bEPART IJiE_._N
BUILDING NT
✓ CONSTRUCTION ADDRESS:3o ti c,L ( o /5
ASSESSOR'S INFORMATION:
Map: Parcel:
lOWNER: C�CJ/ rd a r) BSc) - L . o>3'
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
❑Residential ❑Commercial Est.Cost of Construction$ ia._ C
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
❑ 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:# Replacement doors: # ( Do
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
X Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
017)".2
*The debris will be disposed of at:
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 I.
Applicant's Signature: Date:
✓Owners Signature(or attachment) , . "✓ -" Date: /el/-)/2 )
Approved By: Date. 76 -mil9 Z —
Building Official esi� EMAIL ADDRES
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
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
i , 1 Congress Street, Suite 100
' Boston, MA 02114-2017
e�h_,,s` www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): / , . ! �� (
Address:, at; -v4 R('AGA
City/State/Zip: rrn.)0/-,_-41 M4 0205 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.E I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
9. E Demolition
3.al<m a homeowner doing all work myself. [No workers'comp. insurance required.]t _
10 Building addition
4.E 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 sole 11.E Electrical repairs or additions
proprietors with no employees. 12.]Plumbing repairs or additions
5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs
These sub-contractors have employees and have workers'comp. insurance.$
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.
tContractors 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: f Date: /0/7/�a_
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#: