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Home My WebLink AboutBLD-23-003265 17. O .yqR ) iJ /11 Office Use Only ' O Z /% Permit# ,ytt> ! i / v ,Amount �1I � ��.(/ MATTAGM EU .`°°"°"°��E d Permit expires 180 days from i issue date 13L-D -23-603Zio5 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 DEC 0 9 2022 (508) 398-2231 Ext. 1261 A .? � /�G [3UILUING DEPARTMENT CONSTRUCTION ADDRESS: --- ---- ASSESSOR'S INFO TION: Parcel: OWNER: I C H ( C/a(--/--G_-- 5-(A) 73 C - 7 62 0 d NAME PRESENT ADDRESS TEL. # CONTRACTOR: Pl' I NAME MAILING ADDRESS TEL.# ,esidential 0 Commercial Est.Cost of Construction$ / 7I'2O. ao Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ` 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 /7 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: 2 ' Lout-tor/AZ? I declare under penaltie perju that the statements herein ntained are true and correct to the best(Army knowledge and belief. I understand that any false answer(s) will be just cause for enial or re ocation of y licen and for rose tion under M.G.L.Ch.268,Section I. Applicant's Signature. Date: /a 0 Owners Signature(or attachment) Date: Approved By: — Date: /1 ""Lg 2-4- Building Official desi e) EMAIL ADD S : Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes D. No The Commonwealth of Massachusetts ! iiiii(1, Department of Industrial Accidents 1 Congress Street, Suite 100 4 ,1 Boston, MA 02114-2017 „,,�5�•`'c www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FIL WI H THE PERMIT AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organizatio Individual): 0 4- C)C__ Address: 4 'I_ f'v G i 0 City/State/Zip: Phone #: , 5 O(f---- 173 % ...'7 0 0 0 Are you an employer?Check the . ,. opriate 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. n Remodeling any capacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp.insurance required.] I am a homeowner and will be hiring contractors to conduct all work on my10 [ Building addition 4. ❑ 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.$ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.7 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 t tor. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverag erificati . Aida I do ereby cert' under the pains and penalt' s of perjury that the information provided above is true'and correct. �'�/^ Signature: l • ( _________ Date: (.9?/77430 Phone#: 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#: tiA v-< �a I�- �Q d X