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HomeMy WebLinkAboutBLD-23-001944 r . -3 I 1131 :*"'. yq h ^~,O "+ Office Use Onl} `r0 ifk' Pcrtnitf.- ad "N\, ; tsc_ Amount ,.50•Ut Permit expires ISO days from ' issue date SLD •.a-3 -b0 ►114/4 EXPRESS UILDING PERMIT APPLICATI N TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 70:C- _.... . ..__.-,�-,.. -_1146 Route 28 T 12 2p22 j South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 BUILDING DEPARTMENT 103 wendward way Qy. CONSTRUCTION ADDRESS: T---- ASSESSOR'S INFORMATION: Map: Parcel: 1 victor enright OWNER, 9 t 103 wendward way 508-771-0206 NAME PRESENT ADDRESS \. LQ f1 TEL. CONTRACTOR: harold loyd 103 cart landi circle 774-392-4911 7 y 5-A 1 _ NAME MAILING ADDRESS TEL.# B Residential ❑Commercial Est.Cost of Construction$ 02Ooa`}0 `� 9 Home Improvement Contractor Lie.#156230 Construction Supervisor Lic.#101750 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 1 am the sole proprietor B I have Worker's Compensation Insurance Insurance Company Name: risk StragleS wc500-5017103-2022a Worker's Comp.Polie}r WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove Ei Siding: #of Squares 2.5sq Replacement windows: Replacement doors: # Roofing: #of Squares (❑)Removen existing*(max.2 layers) Insulation L I nI I Old Kings Highway/Historic Dist. Replacing like for like f Pool fencing *The debris brill be disposed of at: yarmouth land) l l Location of Facility t declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledse and belief: I understand that any false answer(s) will be just cause for denial or rev atiioo f , ken and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /. _2 A Date: (!/ Owners Signature(m attachment) /l Date: ' 2>2 The Commonwealth of Massachusetts ��= =, i Department of Industrial Accidents 1 Congress Street,Suite 100 1 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Loxes f t ' Address: (el 3 Cr,-( t; ,f j; (17or`-- City/State/Zip: 46,0 /lac,. 0,2. ' Phone#: '7 e <t- 77( 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. Ei New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. pc Remodeling any capacity.[No workers'comp.insurance required.] 3, I am a homeowner doingall work myself. 9. Demolition ❑ y [No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on m3'property. I will 10 El Building addition 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 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.0we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑OtheF 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: ,`7S/. Policy#or Self-ins.Lic.#: i:'r'C ���v ' 1 7( 2,4l Expiration Date: Job Site Address: [0-3 Ri'icX CI7e--,i i" es-c-,:( City/State/Zip: tc,e-r6nczu1 11f ,,1�'°� Attach a copy of the workers'compensation policy declarati n 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 certify u> er ains and p alties of perjury that the information provided above is true and correct. 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