HomeMy WebLinkAboutApplication',iril.*i;art
lPcrmit cxpires 180 days ftom
lissue date
CONSTRUCTION ADDRXSS:
ASSESSOR'S I}iIOfuVATION:
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmourh. N.[A 02664
(508)398-2231 Ext. 1261I
PRES SS
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CONTRACTOR
)J{\IE TEL, #
Map
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14
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NAI\{E
$&sidential E Commercial
IvAILING ADDRESS TEL:
Est. Cost ofConstruction $
Home Improvement Contractor Lic. #_Construction Supervisor Lic- #_
Workma;o s Compensation Insurance: (check one)
Aurn th" tro*.o*rer -.: I am the sole proprietor
Insurancc Company Namc: _Workcr's Comp. polic}#_
I I have Worker's Compensation Irlsurance
\\'ORK TO BE PE RFOR\IED
Tenl Duration (Fire Retardant Certificate attached?)
?Siding: # of Squares _ Replacement witrdows; # 1,i
Roofing: # of Squares_ ( ) Remove existing* (max. 2 lal.ers)
_ Old Kings Highway/Historic Dist. ( ) Replacing like for like
'The dcbris will be disposed oiat:
Wood Stove_
Replacement door t, l-l
Insulation
Locrtion of Facilir_
I declarc under pena.lties ofpedury
will bejust cause for denial or rev
Appllcarr's Simature
Olvoers Signature (or attrchment)
Approved By
Buit
contained ara troe and correct ro the best ofmv knorvledgc and beltef. I undersland that any false anslver(s)r prosecution under lvl.G L. Ch. 168, Secuon I
Date'
Date:
Date:r desi DR-ESS
Zonirg District
Historical Disaict: a yes I No
Water Resource Protection District:a Yes -No
Flood Plain Zone: _ Yes oN
Within 100 ft. of Wetlandsa Yes I No
Stl;anJ^o^at@rr,,il toYn.
o\lTiER:
I
Parcel:
Pool fencing-_-
The Co mmonwealth of Massaclrusetts
D ep d.rtme nt of I ndustrial A c cidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\Vorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers-
TO BE FILED WITH THE PEI{TvIITTING .A.ITTHORITY.
lica rmatio PIease ntL
Name (Business/OEanizarion^ndividual):
Address:
i$-\
CirylState/Zip:
0
hone #:B-Brs -Gt<+
Type of project (required)
7 trN construction
8.odeling
9 Demolition
Building addition
Elecrical repairs or additions
r0 fl
it
12. I Plurnbing repairs or additions
13. fl Roof repairs
14n Other
. Any applican! thar checki box # I must also fill ou! thc section bc
T Hoocowners who submit this affidavit indicating they arc doiDglconfactors that chcck this box rnust attachcd an additional shcct
low showing thcir workcrs' colDpcnsalion policy informatio[
all work and thcn hira ouBide conEactoE hust submit a ncw affidavt indica:ing such-
showing thc namc of thc sub-contr&toG and statc whethcr or not thosc cntitics haveetuployees. If the suo-contractors have cmployccs,they must providc thcir workfs' comp. policy nuEbcr
I am a clnployer with _cmployces (full and/or pan-timc).r
I am a solc proprietor or pan:renhip and have no cmployecs working for me in
any capacity. [No wortien' comp. insurance rcquired.]
I am a homeowncr doing aU work Eysetf fNo workers' c!mp. insu-ance required.l i
I am a homcowncr and will be hiring contractoG to conduct a.ll work on my propsty. I will
cnslrc that all cootradors eithcr havc wod(crs' compcnsatio! tnsurance or are solc
p@prictors with no rdployccs.
5 . fl I aD a gencral contractor and I have hired the sub-conE-actorr listEd on the atached shcet.
Thcs! sub-contractoE havc cmployecs and have workers' comp. insruancc.l
6.! Wc arc a corporation and its omccrs hava crerciscd thcr right ofcxemption pcl MGL c.
152, S l(4), and we hale no employe.s. [No workers' comp. insurancc requircd.]
2
l
Arc you xn .mployer? Chcck the appropri.te bor
I an an employer that is Providi g worken' compensation insurancefor my enployees. Below is the policy andjob siteinfornntion-
Insuraace Company Name:
Policy # or Seif-ins. Lic. #Exoiration Date:
Job Site Address: Ciry/State/Zip:_
Attach a copy ofthe workers' compensation policy declaration page (showing the poti.y nii-bu. "nd 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 anja fine ofup to $250.00 aday against the violator. A copy ofthis statement may be forwarded to the Office of [nvestigations of the DIA for insurance
coverage verification.
I do hereby de tlte pai penalties of perjury thdt the inform.ation provid.ed abo is tr e and cofiect.
Date
OfJicial use only. Do not write in this arca, to be completed b1 ciry or town official
Issuing Authoritv (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk6. Other 4. Electrical lnspector 5. Plumbing Inspector
Phone #:
City or Town:
Cont!ct PersoIr:
permit/License #