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Home My WebLink AboutBLDX-23-15800 • O !Office Use Only 4%1' � ..co Mnie f i-/c1)(P l J . c1 Amount --- Ct ' I Permit expires 180 days from Y issue date EXPRESS .BU.I.LDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 ' RECEIVED South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 1 DEC 19.2023 CONSTRUCTION ADDRESS: 22 Burch Road South Yarmouth, Ma RtlILUING DEPARTMENT " ASSESSOR'S INFORMATION: book and page 0 D 1085465/ By. ---Map:26/57/// Parcel: 7 OWNER: John T. and Mary bikini 95 Wilfin Rd. S. Yarmouth 203-948-4556 NAME PRESENT ADDRESS TEL. # CONTRACTOR:John and Mary Barrr/95 Wilfin Rd. S. Yarmouth, I 203-948-4556 203-948-3535 NAME r MAILING ADDRESS TEL # O Residential O Commercial Est.Cost of Construction$$4,000.00 Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) B I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: M P I UA Worker's Comp.Policy# WORK TO BE PERFORMED Tent Li Duration ` W (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 6 Replacement windows:# Replacement doors: # Roofing: #of Squares (n)Remove existing*(max.2 layers) Insulation H_ I 1 Old Kings Highway/H'istoric Dist. (Q)Replacing like for like Pool fencing *The debris will be disposed afar: Yarmouth Landfill, Yarmouth, MA replacing siding on 3 sides 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 revocatio of my license and for rosecution unde M.G.L.Ch.268,Section 1. Applicant's Signature: f,,1✓1'� 4, a / li "',. t (C1 3 4 Date: / ow,c4 4 Owners Signature to�ttachmcntj R ��,_,� , Date: I Z 1 I�/ L1 5 Approved By: f� — - — Date: /-?. I.3 Bui •ing Official(or designee) EMAIL ADDRESS: ---_ - Zoning District: Historical District: :_i Yes No Flood Plain Zone: : Yes ::: No Water Resource Protection District: Within 100 ft.of Wetlands: Yes J. No .: Yes No The Commonwealth of Massachusetts =Wry, Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 r.=�•`' www.mass oov/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): John T. and Mary Barry Address: 22 Burch Road City/State/Zip:South Yarmouth, MA 02664 phone#:203-948-4556 Are you an employer?Check the appropriate box: Type of project(required): I.QI am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Q Remodeling 3.01 am a homeowner doing all work myself. t 9. Q Demolition y [No workers'comp.insurance required.] 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sol 11.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.0I 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.: 13.0 Roof repairs 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q✓ Other replace siding on 3 sides of house 152,§I(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. 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 the ains and penalties of perjuryL/iJfrfTh t the information provided above is true and correct Signature: 1> `� 19 l Date: �� Phone#: 20/9L 48-45 6 mdrry 203- 48 535 Jo Yl 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: