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Home My WebLink AboutBLD-23-002706 O1 R / /�_ ,Office Use�Onn1y� 1 • �� 4i0; �/' / 2 Permit# t!�l t�Yl J �ri*1�� . H! +AAmount SO•(50 MATTA H ESE I ;' '4*RO nrtne1 rd:' c Permit expires 180 days from ' *;a.-:-. I issue date 61-'n-43 4/)0?-1ZAr EXPRESS BUILDING PERMIT APPLICATIOR E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department NOV 15 2022 1146 Route 28 ,p''� South Yarmouth, MA 02664 B/ UI:ylnARTME j� (508) 398-2231 Ext. 1261 By CONSTRUCTION ADDRESS: (0 ;J f-nI ft 5 ern j-H- ASSESSOR'S INFORMATION: Map: Parcel: ' OWNER: /i/4 gitpt,J R.Rdtrt..$-e 6 l)4Nn$ Pig TH cr,8 3 C.-7 2.5-8 NAME,, PRESENT ADDRESS TEL. # CONTRACTOR: Mfit e O L.)Ne r NAME MAILING ADDRESS TEL.# XResidential ❑Commercial Est.Cost of Construction$ 5-0 0 0 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) XI 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 > I Replacement windows:# a 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: yA,2_M o.-.TH el:,ff4 rAl 4-11•.vI Location of Facility I declare under penalties of perjury t t 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 rev ation o my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: /1^ /S '2 f Owners Signature(or attachment) Date: //^1S/- Z .. Approved By: v/ Date: // /5 Building Official(or designee IAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 y 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): /V/J{f4 L., /Jp e Address: Co - 4 5 A 7-7- City/State/Zip: rt Phone #: S —3 -25-2 Are you an employer?Check the appropriate box: Type of project(required): am a employer with employees(full and/or part-time).* 7. New construction 2.a I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.AI am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition — 4.0I am a homeowner and will be hiring contractors to conduct all work on mYP roPrh' e I will 10 _ Building addition 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.E1 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.El 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. Signature: 13p/� Date: //— f 2 Phone#: $Z 3 6 ) 2 cO 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: