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3- �� RRitO �� ���.� ;Office Use Only
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s{r' C Permit#_��Y7
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Permit expires 180 days from
I issue date
25
EXPRESS BUILDING PERMITet- 02J 6 6 APPLICAi' D E i V E D
TOWN OF YARMOUTH -- �--�---
Yarmouth Building Department AUG 25 2022
1146 Route 28
South Yarmouth, MA 02664 . ----- _...._
(508) 398-2231 Ext. 1261 BUILDING DEPARTMENT
V
CONSTRUCTION ADDRESS: /a
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ASSESSOR'S INFORMATION:
Map: Parcel:
`OWNER: / ,7L04,i ,
iAME /PRESENTe /)PiaC,W iv(f ' �'L�'''i / A�.I/Ili[
CONTRACTOR: FIDRESS
T SD/7- 9 36W
NAME MAILING ADDRESS
1 TEL.#
1 Residential 0 Commercial
Est.Cost of Construction$ 020d0.00
Home Improvement Contractor Lic.#
Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
lei 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 De o j d e �
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:#
Replacement doors: #
Roofing: #of Squares ( )Remove existing*
b (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 and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature:
�� Date:
�' Owners Signature(or attachment) IP " Q s��c-
Date: V vG-//
Approved By: / �'2�
Building Official(or desig ` Date:
ADDRESS:
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes , 0 No
The Commonwealth of Massachusetts
L. 1 Department of Industrial Accidents
il-�- 1 Congress Street, Suite 100
Boston, MA 02114-2017
":•S www.mass aov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
PIease Print Legibly
Name (Business/Organization/Individual): ‘eit,, 42/4-06e-
Address: /
/ eye iv")
Ci /State/Zi i
' p.��' /: Phone #: --94,z ,
Are you an employer?Check th appropriate box:
I am a employer with Type of project(required):
1.
❑ employees(full and/or part-time).*
7.
2.❑I am a sole proprietor or partnership and have no employees working for me in ❑ New construction
any capacity. [No workers'comp. insurance required.] 8. Remodeling
3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. Demolition
—
4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11. Electrical repairs or additions
12.❑Plumbing repairs or additions
5.0 I 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.El 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 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 der ze pains and enalties of perjury that the information provided above is true'and correct.
Signature:
Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one): Permit/License#
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#:
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