HomeMy WebLinkAboutBLD-23-000488 •��•YAR Office Use Only
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O . ;., I a`"l I zz ;Permit# ��/
�,MAT7A [s[Jd Amount
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'° Permit expires 180 days from
I issue date
EXPRESS BUILDING PERMIT60-023--6d6
APPLICATI
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department - w
1146 Route 28 JUL 2 9 2022
South Yarmouth, MA 02664
• (508) 398-2231 Ext. 1261 — ------
BUILDING DEPARTMENT
CONSTRUCTION ADDRESS: .S-�AN'� ��� -------__
ASSESSOR'S INFORMATION:
/�ryN /Ma/p: L/9 Parcel: " ')
OWNER: A &Wa / / ��—�G (k i�/U
��'' �/ /1 Q t/✓+i nt PRESENT ADDRESS O� �� /���
€6NixTEL. #
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NAME MAILING ADDRESS
TEL.#
-+s ttesidential
❑Commercial Est.Cost of Construction$ .2 7,0,,6)6
Home Improvement Contractor Lic.#
Construction Supervisor Lic.#
Workman's mpensation 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:#I_ _
Replacement doors: #3
Roofing: #of Squares
( )Remove existing* (max. 2 layers) Insulation
Old Kings Highway/Historic Dist.
( )Replacing like for like Pool fencing
t
*The debris will be disposed of at: l4y Ou art/c t4p,�
Location off Facility /"ACC
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 r vocati n of my li for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: f0 Qd`�
Date:
Owners Signature(or attachment)
Date: 3 o
Approved By:
Building Official(or ign EMAIL ADDRES Date: �- 9-.22
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
The Commonwealth of Massachusetts
' 1'. :''':=z'. - 12 Department of Industrial Accidents
1 Congress Street, Suite 100
e • Boston, MA 02114-2017
^".•5 www.tnass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
PIease Print Legibly
Name (Business/Organization/Individual): r.
Address: 1 ; t-- -
City/State/Zip:t,tliEs f; 2-4 Phone #:
Are you an employer?Check the appropriate box:
1. I am a employerwith Type of project(required):
employees(full and/or part-time).* —
7.
2.0 I am a sole proprietor or partnership and have no employees working for me in — New construction
` 3.Aany capacity. [No workers'comp.insurance required.] 8. [ Remodeling
I am a homeowner doing all work myself. [No workers'comp. insurance required.] 9. ❑ Demolition
4.0 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
• ensure that ail 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.$ 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:
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 certi under tl • nd penalties o perjury that the information provided above is true and correct.
p fP .1 Y
Signature: t _ r�l t` Date: 7/?O,2c 6/,1—
Phone#: `i)�t7 — 87
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#:
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