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Home My WebLink AboutBLD-23-001773 'O it Ly n I D I ;j Office Use Only • V 1 Permit# RECEIVED Amount V �� MATTA n CSE W• s...m.,...>... .I Permit expires 180 days from --�- ocT 04 2022 !issue date , EXPRESS BUILDIN FE LçTMNTTCATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7 / Coo/i 0/7 go' toes/ / y, ,< i/1, ASSESSOR'S INFORMATION: JJ Map: Parcel: OWNER: Ayd0/1 6Oyr/'a / '2001dg4 7z-c? 563 ??i0ZCf5 ✓ NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# V esidential ❑Commercial Est.Cost of Construction$ •00 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman),Compensation Insurance: (check one) z/fam 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: # z. t/ 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ,— Owners Signature(or attachment) �?70/ Date: /0 3 — 702 2 ✓ Approved By: // Date: ✓v Building Offici r des' e) EMAIL ADDRE : Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No 0 Yes 0 No \ The Commonwealth of Massachusetts illiffili it Department of Industrial Accidents �?r 1 Congress Street, Suite 100 A i 47 Boston, MA 02114-2017 •`'� _ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ydc i �j E(1,Y t-I q L.,- Address: 7 9 C G o /l c/c1 e 2d t.— ' ' - City/State/Zip: tL/e f yCAMO011 , 6.? Phone #: Jib C Z q SL___, Are you an employer?Check the appropriate box: Type of project(required): I. 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 any capacity.[No workers'comp.insurance required.] 8• _ Remodeling 3.0.f am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp. insurance required.]t 4. ProP I am a homeowner and will be hiring contractors to conduct all work on mye 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. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.t 13•❑Roof repairs 6.❑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 certify under the pains andme penalties of perjury that the information provided above is true and correct. � ft C3T Signature: `,`Ic' GOY()c3 /�i - z� Z Date: 1/ Phone#: 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#: