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Home My WebLink AboutBLD-23-000347 r Mt' YHR C—Gt W Lf 1 -- Office Use Only 1.4 1 Z V/ (/ Amount 1-3 nD.00 MATTA M ESE 4wnc.nEcws End 1 Permit expires 180 days from i issue date &'D-023 6003 f 7 EXPRESS BUILDING PERMIT APPLICATIO 4E C E. II E D M TOWN OF YAROUTH � -� �-- Yarmouth Building Department JUL 212022 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 _ By ------ ✓CONSTRUCTION ADDRESS: L ii ///yf o I'?? r c ASSESSOR'S INFORMATION: Map: Parcel: • r L./OWNER: 61 r-i G, /1 1-7° k r u U&l 3(07- D 7a g NAME / PRESENT ADDRESS TEL. # CONTRACTOR: NAME' MAILING (e /I MAILING ADDRESS TEL.# H'Residential ❑Commercial Est.Cost of Construction$ f 0 C.)C) ,./� Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) l 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: # Replacement doors: # woofing: #of Squares /y ( ,Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 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 revocation of my license d for prosecution under M.G.L.Ch.268,Section 1. Applicant'sA Signature: !/, ,G•7i • Date: 0 7 ' Z I - Z 2 l/Owners Signature(or attachment) Date: (j 2" 2 f Z_2 Approved By: Date: 2 /- 2..,. Building Official esi EMAIL ADD Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: i] Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No �,�� The Commonwealth of Massachusetts A to= Department of Industrial Accidents 1= — `■:�_ 1 Congress Street, Suite 100 � Boston, MA 02114-2017 • r;5 www.mass.00v/dia Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly LA\ianle (Business/Organization/Individual). ,C 9 ✓Address: 2 r ' /141c ve . City/State/Zip: 1% $/ i t`v',,n c;!J1 ./k+riPhone #: 5 3‘ - Z Are you an employer?Check the appropriate box: z‘F3 Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in 8.7. E Rem delinruction any capacity.[No workers'comp. insurance required.] Remodeling — 3.g,am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. — Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my are propertyI will 10 [1] Building addition ensure that all contractors either have workers'compensation insurance or sol proprietors with no employees. 11. Electrical repairs or additions - 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.C Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.x 13,,E1-Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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 pol cy 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 under tlt• ,a' ..-tn-el.; ies o perjury that the information provided above is true and correct. f ✓S�iQnature: --''i!wr, — .�, ' p I rY Phone#: Date: �1 21 — 2_2 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#: