HomeMy WebLinkAboutImage_002.pdf - BLDX-23-15690 26235P.rmit#th
r/).tn
Permit expires 180 days from
issue date
Office Use Only
3 )rs
EXPRESS BUTLDING PERMIT APPLICATION
TO\\N OF YARTVIOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth, MA 02664
(508) i98-2231 Ext. l26l
(nrr*u.rron ADDRESS:
AS SESSOR' S bIFOR]V{,4.TIONI
,/o \{NER:
Mup
Lc
ENT
5el€
I h ottt'1
)NA"\IE TEL 4
CONTR.\CTORI
N,d\IE lvL\ILNG ADDRESS TEL. 4
A fiJ>,m
Workmaqi6 Compensation Insurance: (check onc)!4 am the homeowner I I am the sole proprietor I I have Worker's Compensation Insunnce
esiden!ial I Commercial Est. Cost ofConstruction $
IIome Improvement Contractor Lic. #Construction Supervisor Lic. #
\\'ORK TO BE PERFOR\IED
Du ration (Fire Retardant Certificate attached'l)
4,0,r*r # of Squares Jo Replacement windows: #_
Roofing: # of Squares_ ( ) Remove eristing* (mar. 2 layers)
_ Old Kings Highwav/Historic Dist. ( ) Replacing like for like Pool fcncing
Insuance Compaly Naqe: _Workcr's Comp. poli"y#--
Tcnt Wood Stove_
Replacement doors: #_
Insulation
4re debns will be disposed of at:
I declare under penalties ofperjury
wrll be iust cause for denial or rc ofmy Iicense for p
tion ofFacilit_v
statementi coniarned rue and conect to (he besi ofmy knowledg. and belref. I understand that any false answer(s)
under !1.G L. Ch. 263, sectron I
ADDIic.rnf
/nn*u,
s Signa re
ignature (or attachnent)
Approred By,..
Zoning District
Historical District: a Yes : No
Drte
Drte:
Date
FloodPlain Zone: - Yes lNo
RECEIVED
NoV 27 2023
BUILDING D
l rrt<nt<,."t D co n\urt{ , n<Z-
EPA
Parcel:
lvater Resource Protection Dislrict: Within 100 fL of Wetlaflds:
a Yes -No i Ycs I No
s-\The Commonwealth of Massachusetts
D ep drtme nt of I n dustrial A cc id.e nts
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\1;ot'kers' Compensation Insurance Aflidavit: Builders/Contractors/Electricians/plumbers-
TO BE FILED WITH TIIE PERTIIITTING -AtrTHORITY.
ADDlicant lrtformation Please Print Legibly
N
t/oddress:r9t 0*/Lil', n ) oYhae BA
ame (Busi!css/Organization4ndividual)
CitylStatelZip vilt^t'l1rt ")ti,\
employccs,thcy musr providc thelr workc.s'comp. policy nuDber
Phone #:,.9
7.
8.
9.
t0
Type of project (required)
New construction
Remodeling
Demolition
Building addition
1l.E Electical repairs or additions
12. ! Plumbing repairs or additions
I3.fRoofrepairs
14. fl other
. Arry applicarr thar check box # I must also fill out thc section bclow showingT Honcowners who submit this affidavit indicaring thcy are doing all work anitcont actors that chcck this box must aBachcd an additionat shccishowing the I
thcir workcrs' compcnsation policy information"
thcn hirc ouBide conE_acto6 must submit a new afrdavir indLcating such.
flamc oflhe sub-conractors and stat€ whetler or nor those cnti'.res have
eftployees. lf the su[conE-actors have
Ar! you .D cBploycr? Ch.ck th. .pproprirt. bor:
l.! I am a employer wirh _cmployees (full and/or pan-time).*
I am a sole propaietoaor paroership and have no cmployees working formein
capacity. [No workcrs' comp. insurancc rcquirEd.]
l I am a homcowner doing all work mysclf. [No workcrs, comp. insurarce required.] i
I arn a homcowncr aIId will be hiring contractoG to conduct all wo* on my propclty. I will
ensuc that all conEactors cithcr have workers' compdEalion irsuraDce or arc solc
proprietors with no cmployecs.
I am a gencra] contaactor aIld I havc hircd thc sub,conE-acto6 listrd on t]re attachcd shcct_
Ttrcsa sub-contr&!9c have employees and havc workcrs'cordp. insur-ancc.t
We arr a corpoGrjon and its officcrs have cxcrciscd thcir right ofcxemption pcr MGL c.
152, S l(4), and w. have no employces. [No workers' comp. insurancc rcquircd]
I an an employer tha is provi.d,ing wotkers' compensation insurance for nE employees. Below is the policT and job siteinfornntion
Insurance Compaay Name:_
Policy # or Self-ins. Lic. #Expiration Date:_
Job Site Address: City/Stare/Zip:_
Attach a copy ofthe 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
aad./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 hvestigations ofthe DIA for insurance
coverage verifi
I do here
n.
c oJ perjury tha the information provided above is trud and cofiecl.
lD1
P a lt
I
und.er the pains and
Issuing Authority (circle one):
l.BoardofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Official use only
Phone #:
Do not Y)rite in this area, to be completed by cig or town ofJicial
Contact Person:
Citv or Town:Permit/License #
- bt'l a<25 8rt}-
Z