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HomeMy WebLinkAboutBLD-22-007218 of YAR �.L�L ix) ') p 1,Office Use Only $w p(A I i IPermit# � • ' IPermit# ��y'\ '�! pm i l��l�� 'et ;.. 1 .x Amount 7 .1)6 MA77AGF CSEJd �aN00111.iL0`S�C .. Permit expires 180 days from 1 issue date 6LD - 647?4F EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department —1146 Route 28 JUN ] 3 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTIONADDRESS: kg WCOD PoT drenpc l -© . 3 ASSESSOR'S INFORMATION: { t 1' Map: Parcel: �Z°i 'rl'C�\ OWNER: 1/2C.y1^4- IN 4-g- we-W 6re ��ff r'1 NAME / PRESENT ADDRESS TEL. # CONTRACTOR: // ( NAME MAILING ADDRESS TEL.S # 'Residential 0 Commercial Est. Cost of Construction$ 000, Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm Compensation Insurance: (check one) VI am the homeowner 0 I am the sole proprietor 0 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 /6 Replacement windows: # Replacement doors: # Roofing: #of Squares 20 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Location of Facility 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. Applicant's Signature: Date: Owners Signature(or attachment) Date: 0 b 22 Approved By: Date: Building Official(or signee EMAIL ADDRESS: 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 Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 —imp 5�•`'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le`ibty Name (Business/Organization/Individual): tfln`e,` 1,1 VI -i Address: 4� City/State/Zip:t-JC -- 6)b,-.4-104-11024 Phone #: -L1- -. (3 3 S - q 2 6 L. Are you an employer?Check the appropriate box: Type of project(required): 1.E lam 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 — any capacity. [No workers'comp.insurance required.] 8• Remodeling 3.�am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp. insurance required.] 4.❑ ProPnY 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.❑ 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. These sub-contractors have employees and have workers'comp. insurance.x 1 •❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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. 1.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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: v-t?j A-9 1.11 Date. O 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#: