BLD-23-001269 F .0 •YAR Office Use Only
pt/ q ) q /2 2-- 1
+! Q, i Permit*
O . 11 .,ti},t ;Amount 5-6 do)
"k0+Po""" •.' Permit expires 180 days from
{issue date
40 -a 3-do)ala 9
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
ONSTRUCTION ADDRESS: C4 �y J , YS"f z 1
✓C ,
ASSESSOR'S INFORMATION:
Map: Parcel:
✓OWNER: Iiji l ic,4 . i '--14 ri-�y CJ/ "`'"ij� /.l tS3-`Pck J 3S.3,2 U -/.3./
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
dential ❑Commercial Est.Cost of Construction$ 5�Z0 [/
esi
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's ompensation Insurance: (check one)
1E/ram the homeowner ❑ I am the sole proprietor C 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 -3 ' 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: ttVe Li-,.. L. i r- D 0Location 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.
Applicant's Signature: Date:
✓wners Signature(or attachment) Date: 9- l' Q Z 2..
' Approved By:
Building Official or tg,n "" Date: �'—?� �
( e EMAIL ADDRESS: T
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 0 No
-
\ • The Commonwealth of Massachusetts
' l ''''
IR Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
'''M.m s,• www.mass.gov/dia
«Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TUE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
Name (Business/Organization/Individual): t � kt 4 ��,i n
Address: C i �,4 q-„-.,.t t_SS`t Uaa-
City/State/Zip:c(.9✓1 L.._ Y4c,i, L WV Phone #: I't 3
S /
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
an capacity. [No workers'comp.insurance required.] 8• Remodeling
—
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. -_ Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on myProP rtYe I will 10 _ Building addition
ensure that all contractors either have workers'compensation insurance or are sole
11. Electrical repairs or additions
proprietors with no employees.
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.t 1 •❑Roof repairs
61: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 cer ' der the ins and penalties of perjury that the information provided above is true and correct.
do
ture.
Date: 7- - 26 2_
Phone#: ,St—C k : 6 3 37
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#: