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Home My WebLink AboutBLD-23-003468 O�:YRR � • j I Office Use Only o y101''� . y I Amount 7 5 uJatANAT TACt CSP 1 -,�,wnn.acwv:; .• iPermit expires 180 days from lissue date 23 --60 314 lell EXPRESS BUILDING PERMIT APPLICATION . TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 DEC 2 2 2022 South Yarmouth, MA 02664 (508) 398-2231 Ex . 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: lig- � �� dz. Porh t W UJ e4 Niciyme, / / ASSESSOR'S INFORMATION: Map: �( '^ Parcel: OWNER: tS a�l1 1 ! 1 tYriAii rld C PC1411 SS-97a---8/p 0 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential 0 Commercial Est.Cost of Construction$ q D 00. (..Z Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman' ompensation 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 l Replacement windows: # Replacement doors: # Roofing: #of Squares I . ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing The debris will be disposed. at: C nfirkA 15 GI L cad tion of Facility I declare under penalties of pe,i that the ,i, '�-; - .herein contained aze true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denia or - ecatio Iri r and for prosecution under M.G.L.Ch.268,Section I. 'g (a' - Applicant's Signature: Date: Owners Signatur: or atta' ment) Date: /9 Approved By: [/ Wit-Date: Z�— Building c' r designee) EMAI RESS: 1 oF1✓� 1 1 l�/ V o/S LI IO 97 i 1-co'1 Zoning Dis ct: Historical District: 0 Yes No Flood Plain Zone: 0 Yes lYi io 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 e_ 1 Congress Street, Suite 100 C V`__ Boston, MA 02114-2017 www.mass.ao v/dia `�'`sv b \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): bV t 5 G\''" 1 Address: Tf�YZ9wbY� - ��"I V City/State/Zip: We—Si- \/G(07c2c,4 I i 0/1 Phone #:6 9 . 6 9S q------- Are you an employer?Check the appropriate 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 le proprietor or partnership and have no employees working for me in 8. El Remodeling any apacity.[No workers'comp.insurance required.] 9. _ Demolition 3. am a homeowner doing all work myself. [No workers'comp. insurance required.]t 10 Building addition 4.❑I 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. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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. tContractors 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 verifica • . I do hereby c:, nderi I,:i!ins and penalties of perjury that the information provided above is true and correct. ,� /• Signature: *A/� �/� Date: I a/ 17 - �► Pho,e#: cm .gc 7 9 S - 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#: