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Home My WebLink AboutBLD-23-002103 O&/L4'"�tu ` iJ ini-c-; l Olt' Of y`9R,,_ R E / CO7. Office Use Only s. O r Permit# ��f' S.A.... O(.A ` 'i '. H i ♦ I ) Z 2y(/(/� Amotmt 5 0i MATT M [3t I44 --.0 O I ' P Y 4�"" *•r Permit expires 180 days from i E'+ 'i i +ENT issue date ao e BUILDING PERMIT APPLICATION TOWN OF YARMOUTH _ Yarmouth Building Department R Ef itrE p 1146 Route 28 �" South Yarmouth, MA 02664 SEV 1 ZiOn (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: h1 C �' BUILDING DEPS T N Ry ASSESSOR'S INFORMATION: i Map: Parcel: OWNER: C,e/'9✓t 741,44.6 L1S C/Ippi9A 20 y/9'ei-vDt..t T L ' NAME PRESENT ADDRESS TEL.if CONTRACTOR: 5— --2 261 /z/39 NAME MAILING ADDRESS TEL.# .Residential 0 Commercial Est.Cost of Construction$ ,j L' r O. Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) li,I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove 0 Siding: #of Squares Replacement windows:# Replacement doors: # 'Th/O 6'1176 G /2"--- Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation n 1 Old Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing n *The debris will be disposed of at: t/i rP)O 1 'Tr 5 P— 5'i-i 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. 1 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: �� rfec Date: 6 -2v •-'22s Owners Signature(or attachment) /?q n f Date: 6 2 0 "- Approved By: I�6' /7. Building Offici r d ee) MAIL ADD Date: �� Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No • 0 . -1C- 2(-7 Q—7 -PR)0 C irA c__c__-Ic_pciL) n � 0 7 . The Commonwealth of Massachusetts 1 M r 8 Department of Industrial Accidents rent 1 Congress Street,Suite 100 t4 `' Boston, MA 02114-2017 . 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): 6-eat) jeurv_ ' Address: ii 3 gd _ gi-Zil-ttc City/State/Zip: �e '/l ypi/, C Phone#: 1 - oZ — d 11-17 Are you an employer?Check the appropriate box: Type of project(required): i.❑I am a employer with employees(full and/or part-time)." 7. ❑New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 31KII am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 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 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.t 6.0We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other -_rb�` ::.,. 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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.Lie.#: 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: (" /7 e3 4 t S Date: 6. `7—CD--Z-Z-.- Phone#: geL.g.0-/�S'Y 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: a