HomeMy WebLinkAboutBLDX-23-15771/aonrr*rarroN ADDRE''
ASSESSOR'S N{FOfu\LATION
,r4
EXPRESS BUTLDING PERMIT APPLIC ATIO
TOWN OF YARMOUTH
Yarmouth Building Department
1 146 Route 28
South Yarmouth , MA 02664
(508) 398-2231 Ext. \261
Parcel
PRESENT ADDRESS
iPermid 50-
lPermit
lissue d
expir€s 180 days from
,ts&-zstoo /b\
CONTRACTOR:
,t/Eun-p+ffiE o
DEC r22023
BUILDING DEPARTMENT
By
NANIE illA.lLlN..G ADDRESS
E Residential Est. Cost ofConstruction S
Home Improvement Contrrctor Lic. # Construction Supervisor Lic. #
Workmarl's Compensatio[ Insuance: (check one)I I am the homeowner ] [ am the sole prop.ietor I I have Worker's Cornpensation Insurance
\\ OIIK TO BE PERFOR\IED
Tcnt Duration
TEL J
l.'-
Irsurance Company ,.i..arne: Worker,s Comp. policyl+_
Siding: # of Squares
(Fire Retardant Certificate attached?)
Replacement windows: p_a..'
Roofing: # of Squares_ ( ) Remove existing* (mar. 2 layers)
_ Old Kings Highway/Historic Disr. ( ) Replacing like for like
rThe dcbris wiil be disposed ofar:
Frcilio
I d€clare under penaltles ofperju.v lha! the statemens hereln contained are tfle and con'ect to the best ofmy knowl€dge and belief l understard that any false answer(s)wlll bejust cause lor denial or revo lr ofmv I i,lr prosecution under VLG L. Ch. 268, Secrion I
Applicant's Si
ners Signature (or attxchment)
Date
./""Dat€:
Approved By
Building Oflicia.l (or desigce)E},AIL ADDRESS
Zoning District
Historical District: a yes _ No
Water Resource Protection Disu.ict:I Yes lNo
Flood Plain Zone: _ Yes
Within 100 ft. of Wetlardsi Yes I No
o\
/r_.' 7: /, ili ) /, (z,triht llr/,rtk-
Map:
i Commercial
Wood Stove_
Replacement door r, y'Afu\
/tasvtatioq/b_
Pool fencins
Dale
;b:\
\l:orkers'Comp
The Commonweatlh o, Mossochmetts
Department of Indwtrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
ensation Insurance Affidavit: Builders/Contractors,/Etectricians/plumbers-
TO BE FILED WITH TUE PER.&IITTING .ATITHOzuTY.ApDIi cant Inform ation P ease Print L btYName (Busi,ess/O€anizarion/lndividual):
Address:7 ,e.1 2/274 oe-/'
City/StatelZip:Phone #:Js-l-- aa/b
applicant $ai checki box #l must also fill out the section bclow showing their workers ' compensation policy infonnatio[Homeo\rtrers .rho submit this affidavit indicating tbey are doing all work and then hire ouBide contractors must submit a new affidavt indicaliry suchtcon!-actors that cbcck this bo;must attached an additional sheet showing thc name of the sub-contractors and state whether or tlot tiosc entities haveemployees. Ilthe su[contracto rs have einployees,they must prcvide
L-'
t-
Arc you ao employcr? Chcck the appropriate bor
l.I I am a employer with _cmployees (full and,lor palt_tinE) *
)f] I am a sole proprietor or parmership and have no cmployees working for me inar1y capaciry [No
[[am a homeownc
workeas'comp_ rnsurance required.]
r doing all work myself [No workers' comp. insuEnce requted.] i
I am a homeo$/ner alrd wiil be hiring contractors to conduc! all wod< on my properry. I willensure that all conu-aclors either have workcrs, cohpensation usurance o, *a .irl
_.
propaietors with no crDployccs.
I am a gencral con!-actor ard I have hircd the sub-contractors lrsled on dre attached sheet.These sub-confaclors have crl1ployees and have workcas, corflD. insuGncc I
)
6 ! wc are a corporarion and its officrrs have exercised ther nght ofexemption per MGL cI5l- S t (4), and we haye no employees. p.to *ort.o, "ornflrr,*ncc.lqrur!;l
Type of project (required)
7.
8.
9.
10
New constuction
Remodeling
Demolition
Building addition
t l. fl Electrical repairs or additions
12. ! Plumbing repairs or additions
13
14
Roof repairs
Other
their workers'comp. policy ouhber
I am an emploler that is providing workzn'inlfomutiott compensation insurance for my enplolees. Below is the policy andjob site
Insurance Company Name
Policy # or Self-ias. Lic. #
Job Site Address:
Expiration Date
Attach a copy of CitYTState/ZiP:-
Failure to secure cove*oc r. ..^,,,.ruo.roo,
policy declaration page (showing the poti"y or.ri "oa .rpi.rtilo a"t.y.
ffi'"'#.:,:Ii;";:iffiil.H:t::'.i#,11"i;,ii?;I,it"tr#'#+#,$sffi,Jd[.f:?"",i::."],,11!13333,
::l.HlJit ff"oTlator'
A copv ortr* 't"t.r*t r*fi"i""""i"i.,,r. office of rnvestigations of the DrA for insurance
I do hereby certify under ttte pains and.enalties of perjury tho.t the infomd.tion provided above ts trud and correct.
S e
P ne
City or Town: permiul
Issuing Authority (circle one):l.BoardofHeakh Z. Building Depanment J. City/Town Clerk6. Other 4. Electrical Inspector 5. plumbing Inspector
Phone #:
OfJicial use only. Do not y)rite in this area, to be completed b1 ciq or bwn off.cial
icense #
Contact Person:
L----