HomeMy WebLinkAboutBLD-23-001081 Og•Y,yR Office Use Only
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11, i Permit# I
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` �`°""" p l Permit expires 180 days from
=''1i'' !issue date
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH ----
Yarmouth Building Department I-RECEIVED
1146 Route 28 f 1----
South Yarmouth, MA 02664 AUG 2 9 2022
(508) 398-2231 Ext. 1261
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3UILUING DEPARTMENT
CONSTRUCTION ADDRESS: d�Co� " sY
ASSESSOR'S INFORMATION:
Map: Parcel:
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OWNER:yyf� K Doki,,, V NAME PRE -SS T7e/ 9.22 6 ?
CONTRACTOR: ^,( " E
NAME MAILING ADDRESS TEL.#
iikesidential 0 Commercial Est. Cost of Construction$ �� G , f `-✓' /
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workm 's Compensation Insurance: (check one)
q/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: # I I / Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: Yj412— Vl J )"f Du F A
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: "�`// Owners Signature(or attachment) /� Date: " O� ?- oC
Approved By: ' Date: - 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
terilli ri Department of Industrial Accidents
Pa1 Congress Street, Suite 100
4 Boston, MA 02114-2017
0,M.. ,Iwww.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
ante (Business/Organization/Individual): t4PN D( ,A1 ,`j
Address: eQ61- W /Ail u6 6,LL .
City/State/Zip:1 i Y,I,_ W ,, Phone #: -7 7cf. 0 6-__T—.?
C
Are you an employer?Check the appropriate box:
Type of project(required):
1.E 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
gray capacity. [No workers'comp.insurance required.]
(_f—V,/ 9. ❑ Demolition
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
10 n Building addition
4.C 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.Q 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.$
6.1]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 poiicy 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 u er t pai s an penalties of perjury that the information provided above is true'and correct.
ignature: J o -sC� Date: 1?---- 0`T
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#: