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Home My WebLink AboutBLD-23-003652 ��•Y,qRti Office Use Only • Q 1 ' s,45 Permit# � �"'' -$ ;{Amount i co.id0 MAT1. n fSf °"°°""`°�1 ELP 1 Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 'p 'DZ { 1-ka CZ C lo'1 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 2 .c\'Q. YNNe•e_o 9-rko....— 3'3 Loci — NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# residential ❑Commercial Est. Cost of Construction$ 5 (C'c2"Q Home Improvement Contractor Lie.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) ,BSI 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: # x 'S 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: 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 revo tion of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signatur . r Date: \15\ Owners Signature(or attachment) Date: \ Z 5 1l 3 Approved By: Date: f 11 1 d 3 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • \ The Commonwealth of Massachusetts • , i L Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Imps Workers' www.mass oov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): P1/4.Q\cwivA e VAA0._c:4,-.12K Address: '25r • City/State/Zip: 5. yo,rnn,,.v.____ G2ic.(01-( Phone #: •b11•' 619 • \o, Are you an employer?Check the appropriate box: Type of project(required): 1._ I am a employer with employees(full and/or part-time).* — N 2.a 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.] Remodeling 3.2(1 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 myroe I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.0 Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.El Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 13•❑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(showi(showingthe 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. Signature: 3 Date: k 15'2 Phone#: l&\1 - b°!" — \G5- 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#: