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Home My WebLink AboutBLD-23-001450 '''pTt''YRR C A- Office Use Only • ✓ • t~! �'E /Z-/1 Z- 'Permit# c 9 Ew' „., 'Amount 9®.64?) MATTACM CSCJ�: %oo.Mo.b c ' Permit expires 180 days from issue date 81,D -.23-15e/1/52) EXPRESS BUILDING PERMIT APPLICATlaisE C E I V E D TOWN OF YARMOUTH Yarmouth Building Department SEP 19 2022 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 By._ -- -- CONSTRUCTION ADDRESS: q/S ''" ( Y.4 4"in Cj 7A, G1�j ASSESSOR'S INFORMATION: /,,/ / / /Map: / Parcel: OWNER: �-Z0/4/62_f'`,M '/ ce i �Qf?�70 G� //7 �j�lt% C,c �rJ dGG f �[T 3 NAME PRESENT' TEL. # ADDRESS � � CONTRACTOR: NAME MAILING ADDRESS TEL.# ' esidential 0 Commercial Est.Cost of Construction$ j ac,ei /Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) 'KI am the homeowner 0 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 *The debris will be disposed of at: ;VC(if' 044 tit .0 K /1 ,`j Location of Facility r 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 vocation of my license and for prosecution under M.G. .Ch.268,Section 1. Applicant's Signature:�� ✓� (� L 1 Date: 7/'19/ Owners Signature(or attachment) J 4 ,,gfr Ailfrldilike Date: Q/V Approved By: Date: • Building ici r designee) EMAIL SS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No e .n a 1 / rl' ( 1-‘e-. 1-11 • The Commonwealth of Massachusetts stir- . Department of Industrial Accidents 1 Congress Street, Suite 100 ' • Boston, MA 02114-2017 :.s�•` www.mass.gov/dia \Y orkers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le`ibIy Name (Business/Organization/Individual). / / c S' < GZ �� G' 7 Address: , f� i,1 L2 C City/State/Zip: G G ��AA I � f t/ -� �',� Phone g ,52G'3 — Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp. insurance required.] 8 El Remodeling 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. Demolition — 4.[R'I am a homeowner and will be hiring contractors to conduct all work on mYProPrtY• e 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 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.1 13•❑Roof repairs 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. tContractors 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. Signature: , L �''L'6—ig Date: q Phone#: 0 3 7 .� �f —3 C r !J 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#: