HomeMy WebLinkAboutBLD-23-002618 .41 -a� L Permit# ✓'JJ
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d Permit expires 180 days from
E`" -issue date
��Dy02 3� krRECEIVED
EXPRESS BUILDING PERMIT APPLICATIO NOV 0 202
TOWN OF YARMOUTH 5 0.(5b
Department
Building
Yarmouth -- -—
1146 Route 28 BUILDING D T
ay:
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261 •
ADDRESS: 2filo( LTV b. `z'11 /G�„1",,L4/LCONSTRUCTION ti
ASSESSOR'S INFORMATION: __
Map: Parcel:
OWNER: li ,-iil{Ii/ly,.Vl
s-or .cis 30 Fe.2
NAME IRESENT ADDRESS TEL. # Email Address:
CONTRACTOR
NAME MAILING ADDRESS Tt rA) Email Address:
Residential Commercial Est.Cost of Construction$
700 Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Worloman's Compensation Insurance: (check one)
X_I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: '—`ter Worker's Comp.Policy
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares _ ( Remove existing* (max.2 layers) t Tnsulation
Old Kings Highway/Historic Dist. (l�') Keplacing like for like �'� .�PCaa, ( i5lac/
*The debris will be disposed of at: k‘l (f`A"1
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my lmowledge 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: Q Q LA210A.Cw^ Date: i I ' '3• a03,,D
Owners Signature(or attachment)X( — Date: /I - • 310 a.
JApproved By:
Date:
Building 0 (or I )
Zoning District:
Historical District Yes No Flood Plain Zone: Yes No
Water Resource Protection District Within 100 ft.of Wetlands:
Yes No Yes No
• 1,4c L-ummonweaLrf of lvlassacIsusetts
--.• . r Department of Industrial Accidents
1 Congress Street, Suite 100
\ i <7 Boston, MA 02114-2017
' '.4 „,,,- !v' www.mass.;ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TH H PERNIITT[NG AUTHORITY.
A licant Information Please Print Le 'bl
Name (Business/Organization/Individual): ' I�j / -t5*4- 1 Y\ fimA..
4ddress: 01-- t 1t,t,,SC0 t.it ( jov"...c
1'44i
Jity/State/Zip: 1-1.1/4"-a,-4- " Phone #: k,-�6 0 3076
re you an employer? Check the appropriate box: Type of project (required):
[am a employer with employees(full and/or part-time).* 7. _New construction
I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity. [No workers'comp. insurance required.]
I am a homeowner doing all work myself. [No workers'comp.insurance required.]t
9. ❑ Demolition
l0 ❑ Building addition
n 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.Qbing repairs or additio
I am a general contractor and I have hired the sub-contractors listed on the attached sheet /���� N n
These sub-contractors have employees and have workers' comp. insurance.t 13. oOf repairs !V
We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
t 52,§1(4),and we have no employees. [No workers'comp. insurance required.]
y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information_
imeowners who submit this affidavit indicating they are doing all work and then hire outside cont-actors must submit a new affidavit indicating such.
=actors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
loyees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
n an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
rmatio n.
trance Company Name:
cy# orSelf--ins_ Lic.#: ...---- Expiration Date:
Site Address: City/State/Zip:
ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
nor 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
against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
:rage verification.
hereby certifysunder the pains and penalties of perjury that the information provided above is true and correct.
lature7 `' ._.Q. ,{C, E.n.)/ .Q.Ar '� Date: / I - Ff• , C)aQ
ne#: f 6 07-
)fficial use only. Do not write in this area, to be completed by city or town officiaL
city or Town: Permit/License#
ssuing Authority (circle one):
. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
. Other
contact Person: Phone*:
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