The URL can be used to link to this page

Home My WebLink AboutBLD-23-005929 pF'YR4q L m 4.4205 pay...fa-AL =Office Use Only O : 0 }Permit# ''44.I tbHI � ' !Amount / MATTAI" cQcd I yam1�.O.tC0sGJ Permit expires 180 days from issue date 62D -0 3-GO Sq.9-9 EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH ` wv_-_C_ _ E I V - D Yarmouth Building Department 1146 Route 28 APR 2 5 2023 South Yarmouth, MA 02664 _ (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT ij / /+ BY. CONSTRUCTION ADDRESS: 6° 1�� ` t- 3)a SO3I-4 k Q)4q ASSESSOR'S INFORMATION: Map: Parcel:/ OWNER: iiNA ivy / Lik 4/jo k l ere e �'�/ ck£ k y,,1,44, 4' `, 0a?4P6ePRESENT ADDRES� TEL. CONTRACTOR: `3 3 5 33Q NAME MAILING ADDRESS TEL.# AfResidential ❑Commercial Est.Cost of Construction$ g 1, i O. E Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I 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 <'%' 4 !,› (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 6.01)3 1 Replacement windows:# geil Replacement doors: # Y Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation I i Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: yeifilitt(ftt i r("'rt 1 ct i ec d1," Location of Facility r iI 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 rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ` b Date: Owners Signature(or attachment) .. Date: • Approved By: Date: for,"g ,...... 3 • b Official(or design EMAIL ADDRESS: 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 WNW L Department of Industrial Accidents 1 Congress Street, Suite 100 .k1 PT S'• Boston, MA 021I4-2017 ;,Sv•y,� 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): /,� /, ✓ L3a €Q�/ Address: /® �C � Gre____. / J City/State/Zip: � '/na4A Phone #: Are you an employer?Check the appropriate box: Type of project (required): 1.11 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. I am a homeowner doing ali work myself. 9. _ Demolition [No workers'comp. insurance required.]t 4.❑ ProPrtY 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.E1 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.0 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. 1 •Ell Roof repairs 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]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. S1anature: �� V.2„,37<2,0 23 `" v � � Date: 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#: