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HomeMy WebLinkAboutBLD-23-000831 „,.01.YRR_ Office Use Only • • , ;k O , 1 ,M.., E C F l! ®/ E D 1 Permit# ' il' H i .. — !Amount/�5, �e RATTACM £SC -I `,to.Pa..«,a�„d. i AUG 16 2022 ;Permit expires 180 days from +?'”" i i issue date I__._ _ BUILDING DEPARTMENT EXPRESS BUILDIN 8 CATION TOWN OF YARMOUTH bcp-23--CL`Y Yarmouth Building Department 1146 Rou M 77 /7" c/v Ca( /36 South Yarmouth,MA 02664 6 `� (508) 398-2231 Ext. 1261 XONSTRUCTION ADDRESS: SC( £14On 9.,[,1 i e4� 't(jl,rm.°u-klit O?mot, 1 j ASSESSOR'S INFORMATION: Map: Parcel: XDWNER: MU ro Gl a,(�-12 :() to ot (.,nvv( n Y`,Ce4S'T5 08) 2 7 &F -1 7 7 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# '.Residential 0 Commercial Est.Cost of Construction$ I i(--7UU — Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 17 i 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 A1ding: #of Squares 2, emplacement windows: # 1 5 Replacement doors: # 2 Roofing: #of Squares I ( )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 llloor revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: �p f Date: a / 1/Owners Signature(or attachment) "...e.„," Date: p 'i 3/ 2—Z— Approved By: � Date: / 7---- Building Official esia EMAIL ADDRE Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource'Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes D. No The Commonwealth of Massachusetts Department of Industrial Accidents ' I Congress Street, Suite 100 Boston, MA 02114-2017 `�...5�•y`•y www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): M(,er(TA rA041 V Address: k n v_c,k 1rs U r r 02-6 73 City/State/Zip: Wes\-- y ck ., © Zb13Phone #: 5O g,) 2 2- E""tl7 7 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 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.�I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 [I] Demolition — 4.01 am a homeowner and will be hiring contractors to conduct all work on mYProPrh' e 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. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.; 13 ❑Roof repairs 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]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. T 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: C /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 ains and penalties of perjury that the information provided above is true and correct. 'Sic-nature: Date: Phone#: U 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#: r .0 r t j f. OU9hf the 1101Jc,e nrj r . move 202-2- 1 2_2