HomeMy WebLinkAboutBLDX-23-15519 6F-YR`R
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Pe, it i�tr 180 days from
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EXPRESS BUILDING PERMIT
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APPLICATIO ��- RTMFNT
TOWN OF YARMOUTH ' �\
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664 I ,
(508) 398-2231 Ext. 1261 �` _'
CONSTRUCTION ADDRESS: 3 7 -r R o w 1 E. �c
ASSESSOR'S INFORMATION: EST Mh/ 7"�{ OA6"J 3
(n� ,_, Map: 08 6 Parcel: / 7 2OWNER:J LQflE2Ts/0p / ^
NAME
PRESENT ADDRESS 5D$'7? - O
CONTRACTOR: TEL. #
NAME
MAILING ADDRESS
Residential TEL #
0 Commercial
Est.Cost of Construction$ A___ p•00
Home Improvement Contractor Lie.#
Construction Supervisor Lic.#__._._._______
Workman's Compensation Insurance: (check one)
Xr 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 Duration
(Fire Retardant Certificate attached?)
Siding: #of Squares Wood Stove
Replacement windows: # _
Roofing: #of Squares Replacement doors: #
( )Remove existing* (max.2 layers)
Insulation
.______Old HiQ
KingsHighway/Historic Dist. ( )Replacing like for like
Pool fencing
*The debris will be disposed of at: ..�
SI -►
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
will be just cause for denial or r- .
• ion of my y ense and for prosecutio, der M.G.L.Ch.268,Section 1.
Ir
' that any false answer(s)
Applicant's Signature: L� =
iDate: �Q
Owners Signatur or attachme, %:� S
eta. /Li_,
11111 Approved By: ���� Date: D — . (� . 3
Buil. g O.i''-�''r•`signee) EMAIL ADDRESS: Date: fd�Za<
c • Coal
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District:
Yes Within 100 ft.of Wetlands:
❑ No 0 Yes ❑ No
t *�� The Commonwealth of Massachusetts
Department of lndustria1Accidents
mit—
...ram 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.massgov/dia
.
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information
Name (Business/Organization/Individual): Please Print Leath!
1V
` "' Address: i i t S
• .L .
City/State/Zip: -�-�
..g Phone #: .S -7
Are you an employer?Check the appropriate box:
l.] Type of project(required):
I am a employer with
employees(full and/or part-time).*
7.
I am a sole proprietor or partnership and have no employees working for me in -- New construction
any capacity. [No workers'comp. insurance required.] 8. _ Remodeling
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. — Demolition
4..2I 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 10 — Building addition
proprietors with no employees. 11. Electrical repairs or additions
12.Ej Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp. insurance.$
13.El Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
lit,§1(4),and we have no employees. 14.R'Other
[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 indicatingsuch.
$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:_
7 � 7 I d� om �
Attach a copyCity/State/Zip: jt-LILI
of the workers compensation pol cy declaration rage(showing the policy number and expiration et
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up o Ion date).
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 U 2
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
$ r . a
coverage verification.
I do hereby certify under he pains and p Mies of perjury that the information provided above is true'and correct.
Signatur
Phone#: — L - Date: > — oZ 3
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one): Permit/License#
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#: