HomeMy WebLinkAboutImage_001.pdf - BLDX-23-15521 23142iOlqce use onu#il- 27./ss
lPermit expires 180 days from
tissu6 date
EXPRESS BUILDING PERMIT APPLIC
TOWN OF YAfu\4OUTH
Yarmouth Building Department
I146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
Y Q S/erAt 2r
lvlap Parcel
Xm'rn,
CONTR{CTOR:
N.dvtE
-fam
PRESF;,JT ADDRESS
0-/o> -a83o
NAIVTE
)*.esidential
fen t Duration
Siding: # of Squar
I,L{ILNC ADDRESS TEL, #
- Commercial
ation Insurance: (check one)
Est. Cost of ConstructioR ad).
Hom€ Improvement Contractor Lic. # Construction Supervisor Lic. #_
Iam
Insurance Company Name. _Workcr's Comp. Policy4_
)f, I am the sole proprietor - I have Worker's Compensation lnsurance
\\,ORK TO BE PERFOR"\IED
(Fire Retardant Certifi cate attached?)
Replacement windo$s: &_
( ) Remove eristing* (mar.2 layers)
lvood Stove_
Replacement doors: #_
Insulation
Pool fencins
Roofing: # of Squares_
_ Old Kings Highway/Historic Dist. ( ) Replacing like for like
'ThE debris will be disposed ofar:-f aq
t_ofFacility
and correct ro the best of my
-)4pplicant's Sienan:re
I declare undcr penalties of perjurj- that the stalements herein containerl are truerlrll bejust cause for denial ocation of cense ard for pros on under ILG.L. Ch 268, Section I
knowtedgc and belief. I undersrand that ary false answer(s)
o^., -,/d'26'23
Owtrers Signature (or attachment) Dtte
Approved By DaleBuilding Officia.l (or designee)E\L\]L..\.DDRESS Sqnand
Zoning District
Historical District: _ Yes _ No
lvater Resou.ce Protcction Dist ictI Yes iNo
Flood Plain Zone: - Yes ' Nol
Within 100 ft. of Wetlandsi Yes I No
,COttl
ocT 26
DE
EI v trt-D
CONSTRUCTION ADDRXSS:
AS SESSOR, S TIIIFOfu\L{TION:
S
t<* \
Name lBusines
Address:
The Commonwealth of Massachusetts
D ep artme nt of Industr ial A cc identsI Congress Street, Suite 100
Boston, ll[A 02 114-20 I 7
www.mass.gov/dia
\\:orkers'compensation Insurance Affidavit: Builders/contractors/Electricians/plumbers.
TO BE FILED WITH TIIE PEfuVliT'TING ,{tITHORIT\',
nt Info ation Plea t bl
yganizatioD/lndividual) :-fam o
Q -fz2,t
CirylStatelzip ,tt/et/%o%Phone #:'?3-/n-aeil
Type of project (required)
7.
8.
9.
l0
Il.
12.
13.
14.
New constr-uction
Remodeling
Demolitioo
Building addition
Electrical repairs or additions
Plumbing repairs or additions
Roof repairs
Other
applicsnr thar checks box #l must also fill out L\e section below showing their workers' compensation policy info.mation.
meowners who submit this affidavit indicating they are doing all work and then hire ouEide consactors must submit a new a.fidavit indicating suchtContracoors t\at check this box rnust atrached an additional shect showing the naJn€ of the sub-conL'actoas and stale whethcr or not lhose entities haveemployees. If the suu.conEactors have employees, they must provide &eia workcrs'comp. poliry DuErber
Arc you an employer? Chcck the appropriat€ bo(
I am a ernployer with _eroployees (full and/or part-time).*
I am a sole proprieto.or paroership and have no employees wo.king formcin
any capacity. [No workers' comp. insurance required.l
3.ffi1 am a hooeo*ner doing all work myself [No workers, comp. insurance ,equired.] r
I am a homcorrler and will be hiriry contractors to conduct all work on my property. I will
ensure dlat all confaclors eithar have workers, compensation insurance or arc sole
FoPrietoas with no cmployces.
I aln a gencral co[ts'actor aDd I have hired the suucodfactoE listcd on Lhe atldched shee!.
Thesc sub-conEaators have employces and have workers' comp. insuzncc.t
Wc ar. a corporation and iLs officers have exercised their ngh! of exenDtion per MGL c.
152, S 1(4), and we have no employees. [No workers' comp_ insurance rcquirid_]
4
5
5
I am an employer thu b providing workers' compensation insurancefor my employees. Betow is thepoltqt and.job siteinJormation-
Insura.nce Company Name
Policy # or Self-ins. Lic. #:Expiration Date
Job Site Address: Ciry/Stale/Zip:
Attach a copy ofthe workers' compensation pori.y a""rr.rti* p.g. l.notniogin" poti"y nrrnu". "na "*pi.rti* ax.y.
Failure to secure coverage as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to SI,500.00
and,/or one-year imprisonment, as well as civil penahies in the fonn of a STOP WORKbRDER and a fine olup to $250.00 aday against the violator. A copy of this statement may be forwarded to the Office of hvestigations ofthe DIA for insurance
coverage verificalion.
f4o herebt certi under the pains and penalties of perjury that the information provide
S
d above is true dnd correcL
0-2d- 23
OfJicial use only. Do not write in thb area, to be completed b) cit! ot toy,n ofrtcial.
Issuing Authority (circle one):
l. Board of Health 2, Building Department j. City/Town Clerk6. Other 4. Electrical Inspector 5. Plumbing lnspector
Phone #:
City or Town:
Contact Person:
P