HomeMy WebLinkAboutImage_002.pdf - BSHD-23-102 29418o
+
CO\S TRT ('TIO\DDR[-SS:
EXPRESS SHED PERMIT APPLIC
TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth^ MA 02664
508 398-22 Ext. I 261
PRFST,NT ADDRFSS
0fllce tlse Onl)
Pernrt,
O^"rrr 35,D?
Permit expires 180 days from
issue date
luA
\\ \I:R
CON I R.\C II )R
NA II:
Rm{E lV E D
t)Ec 13 2023
eutrottlc orpnnrni|erur
Ay
N A\{ I:MAIT-ING AI)DRFSS 't[r ,
dRcsidential O Commercial
Home lmprovelnent Contractor Lic. #
I drclarc undcr pcnaltrcsrill beJUsl caLrse lbr drn
Esl. Cost ofConstruction S
Construction Supervisor Lic. #_
,,1
Dare
(or atlachmrnl). t rte
pEqur) lhal lhe statenents hclcln contained alc Irue and correcl to the be5t ofnl] kno\\ledee and b.lief I lndersland that an) falsc ans$€(s)or.E\ocation ofm) hcense and for prosacurion (nder M G L Ch 26E. Scclio l
App,rLJrt s Sr!nrtLr
/<.r" n.,. sisrrr,."
Approrcd B):_Ilate
EN4AII- ADDR!'SS
Historical District: Yes N-o Flood Plain Zone: Yes No
Z,oning District
Water Rciource Prolec(ion District: Within 100 fi. ofWetlands: ***
Yes No Yes No***Note: Conservalion revii,* rcquired if within 100 it. of Wetlands
l/21
aL
Burlding Ollicial (or designee)
Rdepealn@ jodaq ftalar/*tt -(/r^-
l,/
\\ orL,n.y \ ( (,mpcnialion lnsurance {eheck onrt/ I rm the humcos nrr I am the solc proprictor I ha.r e \\irrker.s Compcnsation lnsurance
lnsurlncc Companr Namc: _ Worker.s Comp. polic\4_
./ SHE,D INFORMATION
'l ,-^,/' N"w_ size L /0 ,wl5- *H fr cornerlor: yes y'
No
Pu.'linvt o/ litrrttttrtlr Zorrirtt Bt l,tt ,\r,r. )0.1.5 \t,,t" L,
Replace existing* _ Size L_ _* ,\ H _
'The dchns \Ill he drsp oscd of at
-
4@
t r ation
Name (Bushesyorganization/l Civi
Address:
The Commonwealth of Massach usetrs
DeparIment of Industial Accidents
1 Congress Street, Suite 100
Bostott, MA 02114-2017
Phone #:
PI se Print Le bl
Type of project (required)
New c!nstruction
Remodeling
Demolition
Building addition
Electrical repairs or additions
Plumbing repairs or additions
Roofrepairs
Other
\\iorkers' compensation r"..."'""'#X;If,,t;iouYlrlJarrrr^rr"r"/Electricians,/prum bers.TO BE FILED WITH TIIE PERMITTINC .{TITHORIT\'.
al):
CitylStatelzip o
applicant tha! checks box #l must also frll oul tic sectjon bclow showing thair workaB'cohpensadon poliry inforrnalioniHomco.;r'Dcrs who subIllit thrs affidavit indicating tbey arc doint all work ard then hirc ousidc contractors must submjt a new affidavir Llrdlcating such.1Contractors that check this box must aBachcd ar additional shcct shoqing the namc of$e sub-contractors and state whethcr or hot thosc entities havcemployees. If thc suE.coDEactors have cmployccs, thcy must providc thcir wo
I am a employer with _employecs (full and./or pan dme) r
I a]n a sole proprictor or parbcrship and hale no cmployres working ior m. inany capacity [No work.rs' comp. insurancc rcquircd.]'
I am a homeowner doing all work myscll [No workco, comp. insurancc rcquircd ] t
i aIn a homcowner and will be hiring contractors to conduct a.ll work on my proDcrry I willensurc rhat all contractors cithcr have workcrr. "orp*."rion ,n*r_". ";;'. 4;;.propnctors with no qoployecs.
I arn a gcncral confaoor and I havc hir.d $c sub-conE-acrors Lsrcd on lhc altachcd shcclThcsc sub-contactgB have cmployecs and hav" *o.t"n, "orp. ;;;.i* * *'
We arc a corporatjon and is officers have cxercised their right of€xernptjon per MGL c.I52, ! I {4), and wr hav. no cmployecs. ;No workcrs. compi ins,rr"";;q;;:;l ---
l
)
6
4
rM/
Ar. you r[ .mployer? Chc.k th. .pproprilt. bor
I om an emplo)er that is ptoviding
in1[ormaion-
I-nsurance Company Name
rkers' comp. policy nuober
worken' compensation insurance for m1t employees- Below is the poticlt andjob site
Policy # or Self-ins. Lic. #
Job Site Ad&ess:_
o*r.0, "oo, or ii"l,1rl"r.*m"-*,,", *",Failure to secure. coverage as required.under MGL c. 152, !25A is a criminal violation punishable by a fine up to $1,500.00and'/or one-year imprisonment, as well as civil penaities in the fo.m of a STop woRK oRDER ania frne of up to $250.00 aday against the violator' A copy ofthis statement may be forwarded to the office of Investigations ofthe DIA for insurancecoverage verification.
I do hercby under the pains and penalties of perjury thal the information provid.ed aboye is ttud o.nd coffect.
ate 7-
Phone #
o noljerite in this drea, to be completed b) cit! or town olrtciaL
Issuing Authority (circle one):
l. Board of Health 2. Building Department 3. City/Town Clerk6. Other
OfJicial use only
4. Electrical Inspector 5. plumbing lnspector
Phone #:
D
City or Town:
Contact Person:
I
't l-- l,. LJ
8.D
e.E
l0E
ll.x
12E
13n
148