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Home My WebLink AboutBLD-23-003649 O -ygR ��/" Office Use Only ' \ /,, "I''' . , .. `. . !Permit#(,,. -� /''')I(O f�O/ _ H, (Amount 6-0— \.- .A4.: „ ESE �'• c; 1 Permit expires 180 days from :--"' I issue date SL/D -3-- to 40 EXPRESS BUILDING PERMIT APPLICATI E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department JAN 0 4 2023 1146 Route 28 South Yarmouth, MA 02664 Bui i ENT (508) 398-2231 Ext. 1261 By: CONSTRUCTION ADDRESS: 4 C(e.g-4-1 toe-rat LAC ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 6e� 1 ( Ct179C1 1 PRESENT ADDRESS 50g- c 3i.-coo? 1 ADDRESS TEL. # ti CONTRACTOR: Jam, t, x' NAME MAILING ADDRESS TEL.# "Residential ❑Commercial Est.Cost of Construction$ 4j 30 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 Replacement windows: # I Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/His onf Dist. (,-1 Replacing like for like Pool fencing ( .. - �4"` "' 1 yl03 lilu fit 111u *The debris will be disposed of at: it C(YlO V�'k �v(n 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) will be just cause for denial or vocatio license and for prosecution under M.G.L.Ch.268,Section 1.Applicant's Signature: Date: /kid()0) 3-- Owners Signature(or attachment) Date: j I / O ? J Approved B : �"v Date: t—. --__4t7 PP Y � ��``.� Building Offici r de . e) EMAIL ADDRESS:2----(� 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 . p *-�—=1 Department of Industrial Accidents _ 1 Congress Street, Suite 100 .f s �_ �t Boston, MA 02114-2017 or 0,,= _ www.mass,aov/dia r.Sv ��orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Go 11\,;\----;,....L Address: ? L.v\ \ City/State/Zip: Phone #: 'coo ��L1 ��g Are you an employer?Check the appropriate box: Type of project(required): 1._ I am a employer with employees(full and/or part-time).* 7. El New construction 2.12 I am a sole proprietor or partnership and have no employees working for me in 8. C Remodeling any�capacity. [No workers'comp.insurance required.] ` 3.—v�IIaam a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 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.E Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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 certi under he and penalties of perjury that the information provided above is true'and correct. Signature: Date: \ --'\ —1T 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#: