HomeMy WebLinkAboutBLD-23-000489 _ n :Office Use Only
. !:~b. 0 / /9241� Permit# ( /( ��
O �l,'/�` .$ IAmount 5.0•.66
tA MATTA�OPoO��iLO`�Q�s`d iPermit expires 180 days from
{issue date
&'D—a-3 -ood LA?9
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department --
1146 Route 28 JUL 2 9 2022
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 _ .__
BUILDING DEPARTMENT
CONSTRUCTION ADDRESS:
I 2LLflFV oac_k L.J .r uL.
ASSESSOR'S INFORMATION:
Map: Parcel:
ONVNE R: .„.ua tOnrl CJVL _,. 9 '7q -�-/1d -61'7
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: M2,
NAME MAILING ADDRESS TEL.#
pl Residential 0 Commercial Est.Cost of Construction$ Q�
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
Priam the homeowner 0 I an 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
11—Siding: #of Squares 5 Replacement windows: # Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at:dartMlahTO
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:
/
V Owners Signature(or attachment) Date: Z (c _ 1 I �O„
Approved By: /' Date: 7 —2- --
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes ❑ No ❑ Yes U No
\ The Commonwealth of Massachusetts
1—,'ItifiTV-11 Department of Industrial Accidents
1 Congress Street, Suite 100
\ '� Boston, MA 02114-2017
Iti......5 Workers'
W� ov/dia
orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
Name (Business�s/Organization/Individu I):a
/Address: 1 `UQS I,C
- ick,rrno-ui-11
City/State/Zip: 03CQ Phone #: 14 c O nesi_
Are you an employer?Check the appropriate box:
Type of project(required):
l._ I am a employer with employees(full and/or part-time).* —
7. _ New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
capacity. [No workers'comp. insurance required.] 8. [ Remodeling
3. I amE?PrY a homeowner doing all work myself [No workers'comp. insurance required.] 9 ❑ Demolition
4.1D am a homeowner and will be hiring contractors to conduct all work on property.mY
I will 10 ❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 11.Ell Electrical repairs or additions
5.0 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.t 13.❑Roof repairs
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.
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: 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 cer fy un the pains and penalties of perjury that the information provided above is true'and correct.
Signature: G a a
Date: 7 l
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#: