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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department n-.......--
1146 Route 28
South Yarmouth, MA 02664 AUG 4 2022
(508) 398-2231 Ext. 1261
BUILDING DEPARTMENT
CONSTRUCTION ADDRESS: �,k
�G By _
ASSESSOR'S INFORMATION:
Map: Parcel:
WNER: jleSSei liciro 5 v ✓ 5i N!� dbOtie� (7 74i ) .3 --6. 1-7
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.# /
,, J (//
esidential ❑Commercial Est.Cost of Construction$ US-5— ¢a).
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workm Compensation Insurance: (check one)
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 (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
VRoofing: #of Squares J.L. ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
►i*The debris will be disposed of at: 1100 7)4?T.) rLoca' n of Facaj
ility
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.
plicant's Signature: Date:
Owners Signature(or attachment) �i'FLi Date:
Approved By: 8—�j t��(
Date: Z,
Building Official(or ig EMAIL ADD .
Zoning District:
Historical District: 0 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
_rrf •
Department oflndustrialAccidents
1 Congress Street, Suite 100
I Boston, MA 02114-2017
5.•`'� _ www.mass.gov/dia
��orkers' •
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LezibIy
Name (Business/Organization/Individual): less and Tr) S 4.te,,c e
Address: if cateA d; i 6(/
City/State/Zip: (L1Q91 Y2,1viry in/4- UX 73 Phone #: (7741) 353 - 6-1-1
Are you an employer?Check the appropriate box:
_ Type of project(required):
1. I am a employer with employees(full and/or part-time).* 7. New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp. insurance required.]
3. I am a homeowner doing all work myself. 9. ❑ Demolition
❑ y [No workers'comp. insurance required.]I.
4.dam a homeowner and will be hiring contractors to conduct all work on m YProPenY• 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. 13.❑Roof repairs
These sub-contractprs have employees and have workers'comp. insurance.1
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.
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 der the pains and penalties of perjury that the information provided above is true and correct.
fSi�nature: ra , � _ ;
G+de�s� Date: �ht-a.0i y c:204,Z.2
Phone#:
Official use only. Do 't 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#: