HomeMy WebLinkAboutImage_002.pdf - BSHD-23-88 22924ffi
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EXPRESS SHED PERMIT APPLICA
TO\TN OF YARMOUTII
Yarmouth Building Department
I 146 Route 28
South Yarmouth. MA 0266,1
(508) 398-2231 Ext. l26l
[1c,r-tL La^t
L Ir-Vernoq CT
PRESEN t)DIt Ij ss
l'ernrrt crprres l8{, da\s liom
8 -6Ls_-81!0\\ NI:R U\
(.ON I RA(' I'OI{
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Replace existing* _ Size L
'l he dcbfi\ $rll bc dAposcd ot at
2,
IIAILINC ADDRESS
6 I 0-6',l5-
le +/I\IFI- i
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1t,r. I
y Rcsidential
O Commcrcial
Home Improvement Contrnclor Lic. #
Workman s Compensation Insurance: (chcck one)
I am the homco\tncr I anr the sole proprietor
lnsurlncc Crrmflnv Nanrt
Ner,, y' size
Workcr.s Comp. polic\f_
Est. Cosr of Construction $ J,AOo. OO
Construction Supervisor Lic. f
I har e \\'orLer's ('ompcnsation Insurancc
SHED IN I ORIt ATI()N
t l{t,w lbt ,n 9/Corner Lot: Yes /No
Pcr.,Tow,t ttl Yurnltutl! Zo.nins Br-La$, Sct. 20-t.S Note E:
tlhcrhuil<lingutututliut'cnlpurL.t,l
ldcclrrc undcr pcnJtlrcs otpcrtrlsril he , \t cruse tbr dL,nral or r.n that the statcnt.nls herEtn contatfled are rue and corrccl to the bcsl of m\ lno$ledge and behel I undcrstand that arr\ talse ans*ljr(s)
_x tt'_x H _
I0(x I'x I rli
rcatron ofnr! lirensE and for proscc[lron undrr M
Applrcant s S
O$Il.rs Sign
Approvcd B!
rgI1alurc
nlurc (r)r r .rchmrnl)
t6 J 23
G l. th 168 Scctro
=- Dat€
Date
l/21
CEIVED
IBUILDING DEPARTMENT
NOV 0p,2023
By
---
Zoning District
Historical Dislrict: yes No
Watcr Resourcc proicction District:
Flood Plain Zoner yes
l!ithin 100 fi. ofWetlands: *,r*yes No
No
required ifrrirhin 100 fi ofWetlands
Yes No** *Note: Conser! ation re\.ie$
mLn/f7n arlhy A b dp egm a /, 0K_
Ollice Use Onl!
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o.*", -?5.DD
DaE.
\\'olkers' Compensatio
! I am a sole proprietor or partnership and have no cm
The Commonwealth o1f Massach usetts
Department of Industial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www. mass.gov/dia
n Insu rance Affi davit: Builders/Contractors/ETO BE FILED WITH THE PERMITTING .{LITHORI T\'
lectricians,?lum bers-
P Ieas e rint L ibName (Business/Organizarioa/lndividual):
Address:
Citl/StatelZip.et 11 06DLL Phone#: ZU)- L45- rcql
Arr you an employer? Check the appropriare bor:
Ii nt rm tion
l.! I am a employer with _employees (firll aDd/or pan-time) *
d:l
capaciry [No wo*ers' comp insurance requireC.l
a homeownea doing ali work myself [No workcrs, cornp. insurancc reouired ] r
Ployees working for me in
Type of project (required)
7. lyf New construcnon
Remodeling
Demolition
I0 [ Building addition
Electrical repairs or additions
Plumbing repairs or additions
Roof repairs
Other
8
9
I am a homeor.r,ner and wtll be hirrng contracrors to conouct a.ll worK on mv oroneftvensure rhat all conrraclors erther have workers, .o.p.n.unon ,.ui*J; ";,#;;; "prcprietors with no cmploy.es.
We arE a corporadon and its ollicers have exerctsed their righ! ofexemi 52, S l(4), and we have no employees. [No worken, comp- insu..aace
I will
5 ! I am a general conE-acror a.nd I have hired the sub_contra.toB listed on Lhe attached sheet.These sub-conuacters have employees and hav. *o.k".r, -rt- ,".;;;'*
lt
12
t3
ption pcr MGL c
required l
r4-fl
also fill out the section below showrng aheir work.rs' compensation policy informadoI1,iHomeowners who submit this affidavit indicaling rhey are dorng all work and then
applican! that check box #l rnust
lConfacbrs rhat check this box must anachcd an addirional sheei showing t\e nam€ernployees. If the suuconEactors have employees. they must
hire outside conEacors musr submit a new afidavil indicallnB such.ofthc sub-contractoG ard state whether or not thosc entities havecomp- policy number.provide thcir workers'
I am an employet thst is proyidint workers,
inllormation-compensation insurancefor my emplolees- Betow is the poliq) andjob site
Insurance Company Name
Policy # or Self-ins. Lic #Expiration Date
Job Site Address
Attach a copy of the workers, co
City/State/Zipmpensation policv declaration page (show ing the policy number and expiratioD date).Failure to secure coverage as required under MGL c. 152 , $25A is a criminal violarion punishable by a fine up to $1,500.00and/or one-yeaJ imprisonment.as well as civil penaities in the fom of a STOp WORK ORDER and a fine of up to $250.00 aciay against the violator. A copy ofthis statement may be forwarded ro the Office of Invesrisations ofthe DIA for insurancecoverage verificati on.
I do hereby cerffi under the patns ahd penalties of perjuryiat the information provided above is tue and correcl.
Dare 3PCo-L
to be completed by city or town offciaL.
4. Electrical lnspector 5. plumbing lnspector
Phone #:
Issuing Authori
l. Boa rd of Hea
6. Other
ty (circle one):
Ith 2. Building Department 3. Citv/Tow
Official use only. Do not wrtte in this area,
icense #
Contact Perso n:
City or Town:PermiUL
n Clerk
6