HomeMy WebLinkAboutImage_001.pdf - BLDX-23-15475 20706c
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Permit q(pires 180 days from
issue datc
RECEIVED
EXPRESS BUILDING PERMIT APPLTC T
TOWN OF YARMOUTH
Yarmouth Buitding Department
I1.16 Roure 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. l26l
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TEL #
CONSTRUCTION ADDRESS:
AS SE S S OR' S NFOfu\IATION :
O\!NER t
4L NII o>8c Y
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PRESENT AD S
CONTRACTOR:
.\'-
Nd\itE NG ADDRISS
I Commercial
Home Improvement Contractor Lic. #n/
Insurance Company Name
Est. Co$ ofConstruction S
Construction Supervisor Lic. #
Workmalis Compensarion Insurance: (check one)
D(larn the homeouner ! I am the sole proprietor tr I havc Worker,s Compensation lnsurance
CSesidential
Worker's Comp. Policy#
I os u lation
Pool fencins
'The debfls wrllbe disposed ofat:
Lora of Facilir}-'
I declare under peoalties ofpeiury tha! th€ statements herein are L.ue and coryect !o the best of mv knowledge and belief. I undcrstand thar any false answe(s)wrll bejust cause for denial or revocation y lrcense rosecutlon un Ch. 268, Secrion I
Applcant's Signature
O*trers Signatnre (or ettachment)
Datc: la r)UZ
Dat.
Date:
Mup Parcel
Building Official (or desigoee)EIIL{IL ADDRESS
Zoning District
Historical District: i Yes _ No
lvater Resource P.otection Disticta Ycs lNo
Flood Plain Zone: I Yes f No
Within 100 ft. of Wetlands
- Yes I No
N1
WORK TO BE PERFORI'VIED
Tett z" Duration / (Fire Retardant Certificate attached?).7
Siding: 4ofSquar", 2 Replacement windows: , %'1
Rooling: # of Squares --- ( ) Remove eristing+ (max. 2 layers)
_ OId Kings Highwal./Historic Dist. ( ) Reptacing like for like
Wood Stove !--
Replacement doors: # -
Ao
Approved By:
t fo a tion
Name (Business/Organizat
Address: I
City/Statelzip:,
The Commonwealth of Massach usetts
D ep a rtment of I n dustrial A ccide nts
1 Congress Street, Suite 100
Boston, MA 02114-2017
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\\:orkers,compensatior r..,.",""'#I;Ifl,t;i?r("!;'Ja",rr^"r.,s/Electricrans/plumbers.
TO BE FILED WITH THE pERrIIjTTING .{LTTHORIT\'..t
PIease t b
Y" JE
.4n tll Pt'one #:(rtl -Xt-Iai 3
+
applican! thar checks box #l must also frll out the sectjon bclow showing their workers' compensation policy informatio[Homeowners who submii rhis affidavit indica ng thcy are doitU all work and thco hirc outside cootractors must submit a new atidavit indlcathg such.tcontractoas Lhat chcck this box must attachcd an additional shcet showing thc nalnc of thc sub-contracto.s and sta& whcthcr or no! rhose cntitics haveemployecs. if thc suuconfactors have empl oyecs, thcy must provide their worke$'
n4ndiiid
! I am a employcr with
-employees
(full and/or pan-time) *
a homeowncr doing all work myself [No workers, comp. insurance required.] t
I am a homeouder and will be hiring contracrors to condugt all work on mv DroDcrwcnsurc that a.ll contrac@rs erthcr have worLers' compcnsanon Insiuranca oa'"ra ,lf. '
proprictors 'r/ith no .mployccs.
5.! I uu a gcncral coffiacror and I have hircd thc sub-conE-actors lisrcd on the attached sheet.Thcsc sub-contractots havc cmployecs and have workcrs, comp. no*"":
Wc arr a corporatjon and its officers havc exerciscd their right ofexcmption pcr MGL cI i2, S I (4), and wc havc no cmployecs. [No worken, compl insr"*"",lq"i.iJ_f ' --
Iwill
6
63
,t
.mployees working for mc incapacity. [No worlGrs'comp. insurancc rcquircd.]
! I am a sole proprictoror parhership and havc no
Type of project (required):
7. I New construction
s.Esemoderiny' 211*cae
9. L--l Demolition
I an an employer thot b p
information-
Jnsuralce Company Name
Policy # or Self-ins. Lic. #:
comp. poliry number
roviding workers' compensation insurancefor my employees. Below b the policy andjob site
Expiration Date:
Job Site Address .Je ,*-.rlL-City/State/Zip:1.Attach a copy ofthe workers, compensation policy declaratiou page (showing the policy number and expiratio ate)
Failure to secure coverage as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00ald,/or one-year imprisonment, as well as civil penalties IN the form of a STOP WORK ORDER and a fine of up to $250,00 aday against the violator. A copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurancecoverage verification.
by'
I do herebl certifl under the pains d
ature
of ury that the info on provid.ed aboye$
4r /o I
e and correct.
D
P e#
o not write in thb area, to be completed by city or town ofJicial
Issuing Authority (circle one):
l. Board of Health 2. Building Department 3. City/Town Clerk6. Other 4. Electrical lnspector 5. plumbing Inspector
Phone #:
Official use onQ. D
City or Town:
Contact Person:
Arc you an .mploycr? Ch..k thr .ppropriatc bor:
l0 E Building addition
I l.I Electrical repairs or additions
12. f] Plumbing repairs or additions
l3.fRoofrepairs
14. - other
(-.