Loading...
HomeMy WebLinkAboutBLD-23-002871 O.y4R Jur4 I 1 1,?` Office Use Only ' " . 0 r` ,y 4 Permit# ircsc C Amount'- xe00,,1C04- O c Permit expires 180 days from issue date 64- 49 EXPRESS BUILDING PERMIT APPLICAT ' 23 —66 / , TOWN OF YARMOUTH C E I V E D Yarmouth Building Department 1146 Route 28 NOV 2 3 2 2! South Yaunouth, MA 02664 _______ (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: ? aerheisj& Q 0 C 1114 ASSESSOR'S INFORMATION: Map: Parcel: sf.OWNER: 2•CA v6 64 e�d S r 5.gv�' 4 S� ? —o)©© -5./ 7Z NAN'V PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL..## 14sidential D Commercial Est. Cost of Construction$ 17:C®C4" Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workmas Compensation Insurance: (check one) 3 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 e (Fire Retardant Certificate attached?) Wood Stove 7' /Siding: #of Squares Replacement windows: # Replacement doors: # 7Roofin : #of Squares ( ( )Remove existing* (max.2 layers) Insulation • VOld Kings Highwa /Historic Dist. Re lacing like f r g y ( ✓� p b p life Pool fencmb 6IL OIL Fl iiiii•—41AIM41 Ofi - /The debris will be disposed of at: �121:74 ��L/'[ 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) 11 be just cause for denial ocation of my license and for prosecution under M.G.L.Ch.268,Section 1. i /plicant's Signature: Date: 116 3/2 Owners Signature(or attachment) Date: �� �c Approved By: �E ' Date: 2_ Building 0 (o signee) EMAIL ADS: Zoning District: Historical District: 0 Yes L No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 10 Yes 0 No ❑ Yes 0 No • The Commonwealth of Massachusetts 11, Department of Industrial Accidents 1 Congress Street, Suite 100 1 Boston, MA 02114-2017 www.tnass aov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ,4 PIease Print Legibly Name (Business/Organization/Individual): q.eveLeildt eigeiW*" Address: a 4 P 5 City/State/Zip Oa 56 3 Phone #: 26 - 00- 5 1 Are you an employer?Check the appropriate box: Type of project (required): l.❑lam a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in anca aci 8. Remodeling Y P ty.[No workers'comp. insurance required.] 3.gI am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. [1] Demolition 4.E I am a homeowner and will be hiring contractors to conduct all work on my property. I will €4 E Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[ iectrica]repairs or additions proprietors with no employees. 12.[numbing repairs or additions 5.01 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.t 13. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§l(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. 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 A or Self-ins.Lic.h: 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. 1'do hereby cert,i, under the pains and penalties of perjury that the inforniation provided above is true and correct. Signature: b Date: 11/' o[ 2 Phone#: 5 —"1Do - 5339- 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 i#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR - Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at (i C cw \i rn M Work Address Is to be disposed of oat the following location: • . / • ��� *›-vuie, Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. '11/� Signature of Application Date Permit No. o�' BEY TOWN OF YARMOU i o M; -,; BUILDING DEPARTMENT 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 [� r °°� �r '� 1146 Route�tl •HrCr�149 r: HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: 4 & dtCdt 9a2ei.4. Q Q Y.6.4.-riati4 Orsoui-. tid- N Lvii, ET ADDRESS SECTION OF TOWN "HOMEOWNER" �r �S� - D-51�� NAME Oiv[R PH NE WORK P ONE PRESENT MAIL tNG ADDRESS . 4 P ST 00 4.2663 CITY OR TOWN STA'L'E ZIP CODE The current exemption for `Homeowner' was extended to include owner-occupied dwellinEs of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached structure assessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall submit to the building official, on a form acceptable to the building official,that he/she shall be responsible for all such work performed under the building permit. (Section 110 R5.1.3.1) The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he 1 she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that he / she will comply with said procedures and requirements. , HOMEOWNER"S SIGNATURE '$ ...-- APPROVAL OF BUILDING OF1-1CIAL INSURANCE COVERAGE: I have a current 'ability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. *IP No If you have chec ed ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. AV-.. .---. Check one: Signature of Owner or Owner's Agent A' Agent h:homeownrlicexemp 12,C - --- - -------- __