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Home My WebLink AboutBLD-23-000153 r' R L rn '„//_�` ,Office Use Only ' ' `'' 7 �Permit# Z W jr. 5 :O . . H ;Amount 4...5 OE 60 �1 �" NATTA n LSE �' -,�,4*'.e.o..«o°'e d' iPermit expires 180 days from j issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department -a- -- ---- 1146 Route 28 JUL 08 2022 South Yarmouth, MA 02664 508 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: I e 4 T beu /t / ASSESSOR'S INFORMATION: Map: Parcel: V UWNER: cA,,..; Ni AAA '"AME , �t PRESENTDRESS R,.,- l fl r)i e` rCf #774 CONTRACTOR: NAME MAILING ADDRESS TEL.# / /Residential 0 Commercial Est.Cost of Construction$ c 0.0 O. 0 V- Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm p(s Compensation Insurance: (check one) Ill I am the homeowner ❑ I am the sole proprietor 0 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 tiff Siding: ,#of Squares '2, 5 F Replacement windows:# 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: !I G14 th/ V.k{_ ) 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: 7/�/ c-d a.�'- V Owners Signature(or attachment) Date: /r/�p J....— Approved By: Date: -// - 1— Building Official(or desi ee) ��ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts r ....*,....a . IwZ _ / Department of Industrial Accidents _mak 1 Congress Street, Suite 100 •_�5 ns �=�v Boston, MA 02114-2017 5�.�� _ 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): ,S1 //71 b , J/ di V Address: qg C.#g AI An i City/State/Zip: Y' 6-m r A Phone #: `7 2 L a./„L. 0 g L v,. 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 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling fly capacity. [No workers'comp.insurance required.] 3. I 9. [1] Demolition am a homeowner doing all work myself. [No workers'comp.insurance required.]I _ 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.1 6.❑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 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. /Sinature: Al4It' Date: b 7/ Cd02-0 4.1.>- Phone#: ) 7 y' . /dL U i" 0 It 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#: