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Home My WebLink AboutBLD-23-000326 01- YAR,f e_� ��[ //zz/ � ,Office Use Only `L ? Permit# �.L.a�P {/� C -l Amount/d e, a MATTACt1 fSE � '� „,onto** ad 1Permit expires 180 days from {issue date -a.3 -dDd3Zeo EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ! D Yarmouth Building Department LIT] 1146Route28 South Yarmouth, MA 02664(508) 398-2231 Ext. 1261 BUILDING DEPAR-TMENT CONSTRUCTION ADDRESS: 9 t r I J J e 1, SoG \ ASSESSOR'S INFORMATION: M, ap: L��,� tip `' l Parcel: G 6 OWNER ht-� Cc r TAP. K.tc�.arikc ! VVdd1 Pt I1(NU`e 5. Y(Jv,mUlrj rfl 14 a'(1:10 rl NAME •J PRESENT ADDROSS TEL. # CONTRACTOR: ,s0.1n.e NMVIE MAILING ADDRESS TEL.# PS Residential 0 Commercial Est.Cost of Construction$ O6C), Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) Pl I 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 daP .(4, Siding: #of Squares eplacement windows:# l36ACe eplacement doors: # 13 GtI,wtv,.90ws*c�laic 6t� cr. eiL ��t�� Roofing: #of Squares ( ) Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ---IT)W If\ 0-6 YCLA LQ,, 9 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 and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachment) c �p Date: Approved By: Date: / Building Official(or tome EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No �� The Commonwealth of Massachusetts j,Eit Department of Industrial Accidents ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 • �M..5�• _ www.mass ovv/dia \Y orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):I Rl (3,-, COS Address: 9 ,s v..e__) o66)1' r City/State/Zip: 5. � hl, G" Phone #: -7 �� - ( �' ( ? Are you an employer?Check the appropriate box: Type of project(required): LE 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. Rem delinruction any capacity. [No workers'comp.insurance required.] ❑ olig 3.EZ I am a homeowner doing all work myself. [No workers'comp. insurance required.] 9. C Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees. 11.ElElectrical repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 1 •❑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: 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 certify under the pains and penal of perjury that the information provided above is true and correct. Signature: Phone#: 9 /O / Date: 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#: