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HomeMy WebLinkAboutBLD-23-001349 O04'YRR`r n (II l u I 7 Office Use Only Permit#C ldi ' Amount E„�(J. .06 nnrri.cn 5.. , ,.��..�0. j Permit expires 180 days from {issue date 1.1 EXPRESS BUILDING PERMIT APPLICATIONS 3 ..6b 131 TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 --- -.-M- __ - South Yarmouth, MA 02664 SFP 132 2] �� (508) 398-2231 Ext. 1261 y CONSTRUCTION ADDRESS: d/ 6��� `f W 6 07) 4w BUILDING DEPARTMENT Ay. ASSESSOR'S INFORMATION: Map: Parcel: �j r ,/ OWNER: x /-W72 g K A,.&ee-v /(- �� ( 02,1 d' j .(� '©O 76 d ~ � I 7 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# i sidential ❑Commercial Est. Cost of Construction$ �oz e el U Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workmar)is Compensation Insurance: (check one) VI 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 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 4 f*The debris will be disposed of at: O/7 f, k AL 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..0 Applicant's Signature: , / A f Date: Owners Signature(or attachment) Ittei egg ia. Date: g / ,3 -C'�'T. Approved By: ..40 1_i er Date: 7 �9 2� Building Offi '�'ot:gnee) EMAIL AD l id.S: ' if i i l 2�n ,, pi et_ Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes ❑ No • The Commonwealth of Massachusetts r Department of Industrial Accidents , 1 Congress Street, Suite 100 Boston, MA 02114-2017 °'� _�'`�� _ www.mass.gov/dia \j orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly ame (Business/Organization/Individual): •'� A /GCer Address: l & t ) o. A City/State/Zip: ok17 / �a rY{ Phone #: `7 7 -/‘ g 7 Are you an employer?Check the appropriate box: 24 4.-6f Type of project(required): I.❑[am a employer with employees(full and/or part-time).* — 7. ?.a I am a sole proprietor or partnership and have no employees working for me in — New construction 8• capacity.[No workers'comp. insurance required.] _ Remodeling 3.Iaam a homeowner doing all work myself. [No workers'comp. insurance required. 9 _ Demolition ] 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.El Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-corm-actors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 13•[1 Roof repairs 6.E 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 certi u der the pains and _ nalties of pe 'ury that the information provided above is true'and correct. /S iunature: l Y Phone#: % — Date: �f ��� 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#: