HomeMy WebLinkAboutBLD-23-000341 F.yRR cc J e �j / �� j E::
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I issue date
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department RECEIVED
1146 Route 28
South Yarmouth, MA 02664 JUL 20 2022
(508) 398-2231 Ext. 1261
/�Q- �j BUILDING DEPARTMENT
CONSTRUCTION ADDRESS: (ri J (/ ft 8fiCQK /ZD By:
Y --------
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: DI L s0A) SunAA) Sein4' )*- q6/--7c Of
N PRESENT ADDRESS TEL. #
CONT TOR:
NAB MAILING ADDRESS TEL.#
esidential ❑Commercial Est.Cost of Construction$ 3 shoo• OO
Home Improvement-Contractor Lic.# Construction Supervisor Lic.#
Workman's pensation 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
7 Siding: #of Squares / Replacement windows: # Repl cirkeE c QoriT #,
444)
Roofing: #of Squares iq ( )Remove existing* (max.2 layers) tip�:t_!Eti.202----—_'-i.
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fe ci .__... _1 !
By_ RTMENT f
*The debris will be disposed of at: O �� O0/e �-, �`
Location of Facility
I declare under penalties of perjury the st ents 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 revo tiont f m ' se for prosecution under M.G.L.Ch.268,Section 1. v
Applicant's Signature: Date: q id-d / O
Owners Signature(or attachment) ,/� Date:
Approved By: ..-y�7� �/ Date: 7 —2S—2 Z
Building cr designee) EA.IL ADDRESS:
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No C 0.?
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
\ The Commonwealth of Massachusetts
1? IV
Department of Industrial Accidents
;,it 1 Congress Street, Suite 100
Boston, MA 02114-2017
,,,,'''~ www.mass.gov/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): 0 it( Li' 5oA) 3Lifil AiL)
Address: (S� (/ )1t /?ícc', /2. 1) .
City/State/Zip: (JL/ d J?,11 s�l1-\ Phone #: , ../r "- 9('/ �' �"
Are you an employer?Check the appropriate box:
Type of project(required):
1.E 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 8. ❑ Remodeling
anyny capacity. [No workers'comp. insurance required.]
` 3.I;Iyam a homeowner doing all work myself [No workers'comp.insurance required.]t
V 9. ❑ Demolition
4.
I am a homeowner and will be hiring contractors to conduct all work on myproperty. 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-contractors have employees and have workers'comp. insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.11 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 certify under th atnsNrjd penalties of perjury that the information provided above is true and correct.
0
Signature: _ o 2 v 1 '�
�.__ Date: 7 / ! 2' G
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#:
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