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TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
]officc Usc onty
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Pcrmit €xpires lEo days ftom
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RECEIVED
BUILDING TiEPARTMENTBv:_-CONSTRUCTION ADDRXSSI
ASSESSOR'S ITIFORN'IATION:
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Map Parcel
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NA.VIE TEL, #
CONTR\CTOR:
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/nesiaentia
iIAII-ING ADDRESS TEL :
! Commercial Est. Co$ ofconst uction $D
Home Improvement Contractor Li.. #_ Construction Supe rvisor Lic. #
Workma,'s Compensation bsurance: (check one)
d I am rhe homeowner ] I am the sole proprieror
Tnsurance Company Name: _ Worker's ComD. Polic!4
- I have Worker's Compensation Insurance
WORKTO B E PE,RFOR,\IED
Te[t Duration (Fire RetardaDt Certificate altached?)
Siding: # of Squares Replacement windows: #_
Rooling: # ofSquares_ ( ) Remove ef,isting* (max. 2 layers)
_ Old Kings Highway/Historic Dist. ( ) Replacing like for like Pool fencins
slrdar
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olr{
/*tre debris will be disposed of a!:*
Location f Facilir)-
I declare under pena.lties ofpeajury that the statements herein contained ate true and conect to the bcst of my knowledge altd belief. I understand that any false answe(s)
will bcjust cause for denial or revocation of my liccnse and for prosecution under tvl.C.L. Ch. 258, Section I
Applicant's Signature Date
(Owtrers Signature (or attachm€nt)Date:L e
Date
Building Official (or designee)EV[,\IL ADDRESS
Zonirg District
Historical Districti a Yes I No FloodPlainZone: , Yes lNo
W'ater Resource Protection Distict
a Yes aNo
Within 100 ft. of Wetlands
: Yes I No
Approved By
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Wood Stove_
tReplacement doors: # dL
Itrsulation
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CitylState/Zip:
The Co mmo nwealth of Massacltusetts
D ep artme nt of I n dustr ial A cc idents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\\:orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers-
TO BE FILED WITT{ TIIE PERNIITTING .4TTTHOzuTY.
t orm Please Print
Name (BusinesyOrgarization/lndividual):nn4._
Address: Z \$_
Phone #:,1ILJ I -10Y
7.
8.
9.
10
1l
Type of project (required):
New construction
Remodeling
Demolition
Building addition
Eleccical repairs or additions
12. ! Ptumbing repairs or additions
Roofrepairs
Other
13.
14.
*Any applicant that check box #l must also fiil out the section bclow showing thcir workers' coEpensation policy infomatio[
T Honeownen who submit this af6davit indic.dng they are doing all work anJ then hire ouBide confa.rors must submit a ne,J/ afrdavir indicaring such.tconu-actots that check this box dust attachcd an additional sheei showing L\e name of the sub-conEactoB and state whether or not those entities have
Arc you aI e6ployer? Ch.ck thc appropristc bor:
I lllg{enployer wrrh _cmployees (full and/or pan-rime).*
Zffiasolepropieloror parmership and have no cmployees working formcin
I am a hooeowner doing all work myself [No worke6' comp. insurance required.] i
I anl a homeowner ard will be hiring contractom to conduct all work on my property. I will
ensure that all codtractors either havc workeis' compensation uulralce or arc sole
proprieto.s witi no cmployees.
I am a gancral conu.actor and I have hired the sub-cont-actors listed on the aftached shect.
Thesa sub-contractgrs have employecs and have workeas, conp. insufancc.,
We arc a corpoGtioD ard its officcas have exercised their right ofexemption per MGL c.
152. ! I (4), and we have no employees. [No workers' comp. insurance requircd.]
4
5
5
l
ity. [No workers' comp. insuance requircd_]
empioyees. If thc sub-conFactors have employees, they must their workcrs'comp. policy number
I am an employer thal is Provid.ingworken'compensationinsurancefor my erEloyees. Betow b the policy and job site
infornwtion-
Insuraace Company Name:
Policy # or Self-ins. Lic. #Expiration Date
Job Site Address: City/Statdzip
Attach a copy ofthe workers' comPensation policy declaration page (showing the policy number and expiratiou date).
Faiiure 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 forwaded to the Ofiice of Investigations ofthe DIA for insurance
coverage verification.
ate
Pho 1
Official use only. Do not x,rite in this area, to be completed by city or town ofJicial
lssuing Authority (circle one):
l. Board of Ilealth 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
PermiUlicense #
Phone #:
Citv or Town:
Co nract Person: