HomeMy WebLinkAboutImage_002.pdf - BSHD-23-87 22915( )tllc. tise Onl!
Permit#
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Psrnrr e\pres 180 dals ,rom
iJsuc date
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CONSTRUCTION ADDRESS:
(.ONTRACI OIT
NAMIJ
-Kesidenti.rl Commercialrf D'
llome lmprovemenl Contractor Lic. !
U orIm9p,:s ( ompcnsilq{rn lnsuranccy' I am the honrcusncr
EXPRESS SHED PERMIT APPLICAT
TOWN OF YARMOUTT{
Yarmoulh Building Department
I 146 Route 28
South Yamrouth. MA 02661
(508) 398-223 I Ext. l26l
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PRESENT ADDRESS I Fr, ,
\1,\II-IN(i .\DI)RI]SS Tt'L I
4"'"z lt2 r\t,O rH_
E5r Co\r of Construcrion S RDb -
Construction Superrisor l-ic. H
I hare \\'orker's ( ompcnsalion Insurancc
SHEI) INl.'o RM,{.TION
Corner Lot: Yes
(chcck onc)
I am thc sole proprictor
lnsurance Complnr Narnc
Size
---Workcr's
Comp. policl#
Replace existing*_ SizeL n,,'
9/*rfrc aeuns rvrtt tr arsposcd ol'a '
i)rplrLJnr 5 \'!'rJlurc
y' o* ners sigoarurc qrr
I dcclare tlndcr pcnalrtcs ol pc\\rllbcjLrn cruse Ior dcnrrl or
rJUO lhat the stittenlcnts h(retn cdnatncd arc trrlc and correcl k) thcr)n olnr\ hcens. and li)r pn)see lron lndcr i\l C t Ch lrrll
bc\t ot nl\ lnolllcdgc itnd belrel' I und.rstand thal ar\
Drta:
Buildrng Olticral (or destglee)D eE]\IAIL ADDRESS
r a(lllchmratl
Approled Bl
Zoning District
Historical Disrrict: yes No Flood plain Zone: yes
Water Resourcc Protection District: Within l0O fi. ofWetlands: i*.Yes No yes Nol**Notei Conservation revierr required if within l0O ft. of Werlands
CEIVqD
llov 03 2023
zutLDtNG DEPARTM €N.I
CGf vrne-,,^b'."f \de- kE C-\a!-6D .Clvi...l ll
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$5rmuuf[,'}*S-s B.
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P:! !ow,! 0l Yarm rc E:
No
\\'orkers'Compe
The Commonweakh of Massachusetts
D ep art me nt of I ndustrial A cc idefl f S
1 Congress Street, Suite 100
Bostott, MA 02114_2017
trtew.mass.gov/dia
nsation Ins u rance Affidavit: Builders/Contractors/Electricians/plu mbers,TO BE FILED WITH TUE PERNIITTING ALITHORITY.
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Name (Business/Organization/lodividuai)$-rtrn e-/l
Address:
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City/Srate/Zip Db)fr".*6b?-3 -3i3t
'Any applicanr thar checks box I mun also 6ll out thc sccrion bclow showing thcir workcrs'cotl1pensation policy informalron.I Homeowners *ho s,-rbmir iht affidavr! indicating they are doiDg all work and rhcr hire oursidc contradors must submit a ncw afiidavit indrcating suchlcontractors that check fiis box must anached an adCitional sheei showing the name ofthe sub-contractors and statc whether or not those cntilies haveemployees. Ii!he sub-con!racroas have ahpl
Type of project (required):
New construction
Remodeling
Demolition
Building addition
Electrical repairs or additions
Plumbing repairs or additions
7.
8.
9.
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1t
l2
l3
t4.WOth "'D.J.sh! Roofrepairs
l.! I an aerrployer with _cmployees (full and/or pa(-time).1,tr l:.T-:_Y:-*:$,.tor or pann.rship ard havc no cmpioyees working formcrnany capzcrty. [No workers comp insrra,rcc rcqrrred.]'
l.Q/am a homcowncr doing all \r,ork mysclf {No workers.comp. insurancc rcquired.]r
o fl1* " l:T._")."r and.,vill bc hiring conracrors ro conducrall work on my prooerry Iwicnsurc that all contractors eithrr have work ers , co, pana",ion inaurrnaa or ara rot.
_
propricbrs witl no chployccs.
5 [ I am a gencral contraclor anC I have hi.cd thc sub-con-.ractors lislcd on the anached sbce!These sirb-contracrors havc cmploycss and have workers, comp_ il;;;.r-* *
Wc are a.corporarion and its offlccrs have cxcrcrsed their righ! ofexemI52, ! l(4), and we havc oo employees [No workers,corapiinsurance
5
re you rn employ.r? Check th. rpproprixtc bor:
ption per MGL c
required l
I am an e.mployet that is providing.reorkerc, cotrqormat@n.ntpensatio,t i surancefot my enplqrees. Below is the policy andjob site
Insurance Company Name
Policy # or Sellins. Lic. #
oyees,thcy musr provrde their workcrs'comp poLicy number
Date
Job Site Address:
attr.t o "opy or Ciry/State/ziD:
Faii ure to s ecure coverase as "r,',il, il".i_:[' rH:i: :];tffi ;i:: ::ffi * # ,o.# J ;',and/or one-year imprisonmenr, as welr as civil p"r"ltj;;;; il;;;ja srop woRK oRDER anja f.ine of up to $250.00 a:3.:!I;:ff""#:Tor' A copv orthis s"","",o,"f-i"'i";;il;; tle orrice orrnvestg"i",. "r,i"'ira ror insurance
I do hereby auler the pains aitt pennlties ojperjury tho.t the in/orntaliort prot'ided above is true and coffecl.\,-Zone;
lo be completed b) city or totun officia!.
City or Torvn:Perm it/License #
{. Electrical Inspector 5. plumbing Inspector
Phone #:
OlJicial use onl!. Do notwrite in this area,
Department 3. Cir]-/Town Clerk
Con tact Person:
lssuing Authoriry (circle onel:L Board of Health 2. Buitding
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