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HomeMy WebLinkAboutBLD-23-000562 ;Office Use Only R ' C, 3 k Off'~Y R Permit# ° q 07f O _ y 'Amount , `"4nArrAcn rase_'� Permit expires 180 days from �`°^°•••Se°'�'c d {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 AUG 03 2022 (508) 398-2231 Ext. 1261 04/ /07/1117 G�C7� ©y:BUILDING DEPARTMENT CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: Parcel: f Mar—T- 1- f'> /-ers 6/7— 6 -- '70 6 V OWNER: N ��--DD,,//JJ PRESENT ADDRESS--(.. .) TEL. # CONTRACTOR: .reit' l 4- ) TEL.# NAME MAILING ADDRESS iResidential 0 Commercial Est.Cost of Construction$ 6 Q Q. Home Improvement Contractor Lic.# Construction Supervisor Lic.# Work./s Compensation Insurance: (check one) I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED ,penld b i' e1 IC ncis9'q al et- Tent Duration (Fire Retardant Certificate attached?) Woo Stove Siding: #of Squares Replacement windows: # Replacement doors: # 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: Te,u7/lf Y�i9 te 0 �, 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 r license and for prosecution under M.G.L.Ch.268,Section 1. Date: - 3 - 2oZ.Z Applicant's Signature.Owner 7 ✓/ Date: R-'✓ 70 2� Approv Signature(or attachment) _ � Date: Approved By: Building ial esig e) EMAIL SS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts � D� epartment of Industrial Accidents A _ok_�rel- 1 Congress Street, Suite 100 Si r`- 4 Boston, MA 02114-2017 No _ www.mass.gov/dia ��orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / Please Print Legibly /-Name (Business/Organization/Individual): ,4 e/2 / 7-- ""L�&�`--� . (7/l Address: 231) 0 L-i) rn 41/ City/State/Zip: ' yi9, 1)///7/‘ 12 Pone #: 4 / 7 r 3 2-6 , 74' b V Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Ell Remodeling an capacity. [No workers'comp.insurance required.] �/ 3I am a homeowner doing all work myself. [No workers'comp.insurance required.] 9. Demolition • Building 4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.El Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp. insurance.] 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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 under the pains and penalties of perjury that the information provided above is true'and correct. Date: Signature {- — '?-r/ *2---,- _ Phone#: b/ "7 - "Zt) 7 e (o 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#: