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Permit expires 180 days from
issue dat€
$t.DY -Jj-/ttr2/z
EXPRESS BUILDING PERMIT APPLICATION
TO\\N{ OF YARMOUTH
Yarmouth Building Department
1 146 Route 28
South Yarmouth. MA 02664
(508) 398-2231 Ext. l26l
*/
DEC 28 2023
AUILDING DEPARTMENT
CONSTRUCTION ADDRESS
ASSESSOR'S TIFOfu\LATION
5 eri
h LO VvNER
/GResidential
CO\TRA.CTOR] P{,T7 /Lk
Parcel: al
-3 t
(hl-r--
TEL, }
ozlcl 77t1o6 j1 'l
Construction Supervisor Lic. i---
N
NAr\tE
Du ration
PRESENT .,\DDRESS
t L<7
i Commercial l rc llt Hil
TEL #
Est. cost of construc r*"$ Jhl0.0O
Home Improvement Contractor Lic. #CSFI+ ' [oe, o,.lz
|!I,\]LNG AD
Workman's Compensation lnsurance: (check one)f I am the homeowner EI am the sole proprietor I I havc Worker,s Compensation Insurance
lnsurance Company Name No Afolt , fttJ Ia^"\4'orker's Comp. Policya_
Tent _
\\'ORti TO BE PERFORTIIED
(Fire Retardant Certificate attached?)
Uo Ra'fu"&*" rF"##,"No,tr?r:i.r.c,
Siding: # ofSquares _ Replacement windorvs: #_
Roofing: # ofSquares_ ( ) Remove eristing* (max.2 ta_vers)
_ Old Kings Highway/Historic Dist. ( ) Replacing like for like
Replacement doors: #_
Insulation
Pool fencing
Da!.tz -a1 43
L- Z1- Z1
Dale
'The debfls wlll be disposed oirt 5 (ca<
Location of Fr
I declare under penalties ofperjury that the statements herein contai0ed are true ard corect to the best ofmy knowledge and beliei Iunderstand that any false answer(s)
\rill bejust cause for denial or revoc for prosecution under lvl G L Ch. 268, Section 1f m," Ilcensc
Owners Signature (or lttachmeot)Date: I
Approved B-,'.
Building Officra.l (or designec)E\L\IL ADDRESS
Zoning District
Historical District: a Yes : N.-o
lvater Resource Protectioo District
i Yes JNo
FloodPlain Zonei I Yes lNo
within 100 ft. of w.tlands
a Yes I No
rt?-Llfffi{A Cymcas-q. rtzf
Map:
Applicart's Signature
RECEIVED
iE-\The Commonweahh o1l plassoch usetts
D ep art ment of I n (l ustr iat A c c idents
1 Congress Street, Suite 100
Boston, MA 02 114-2017
\\io.kers,compensation r"r,.,r""t;f;fr?,tr"r?rY:::rrr*rctors/Erectricians,?lumbers.
TO BE FILED WITH THE pERT}IITTIr\*c ALTTHORITY.ior tion
Name (Business/Organizatio lndividual)
Ii Pi se Print
/
Address: 5 cZ4+A
l.! I am a homeowner doing ail \&ork mysell [No workers. comp_ insuEnce r.quired.] i
CiiylStatetZip
,F
aLny applicanr rhat checks boi,
i am a employer wiih =-cmployees (full and/or pan-rime) ,
I alrl a solc proorielo. or pannership and have no cnployees workinq for m€ inany capaciry. INo *orkcrs' comp. ir.:suia:rcc rcquired_]
)L7b-ZPhon #-79 ) -3o6-a 11 1
Type of project (required)
Z. ._-1 New constructjon
modeling
emoiition
Building addition
8.
9.
10l_T-1 f,:T?*r"l -O *rlt be hirint conrractors ro condrct a| work on ny proo€rrJ, I witiensura ttrat alt connactors etther hava *orkers. cor:pelsation insurance or are sole '
propricio.s wiLh no ernployecs.
I srn a gencral contsacror anC I have hi.eC thc sub-con-racloas lisrcd on Lhe altached shee:Ihas! sub-contaactors havc cmployaes and havc workerr, comD. insurance t
6.! We a;c a corporation and its offic..s have excrcrsed rherr nghr ofexeinptron ,er llGL cl5l, ! I/4), and we hav: no employees lNo workcrs, conp-rnsurrr..i.q;irij.l'
I Lf ElectTical repairs or additions
12. f, Plumbing repairs or additions
13.f Roof repairs
14D Other !-ar+6 l)rr<"t
I must also fill out the s.ction below rr work€rs' cornpensaljon policy jnfomauon
ae: showing the rame ofthe sub-contiactors and siata whcthcr or not thosE cntitiess, tney mlst provide their woakers'
showing rhc
lconrraclors haa che.k .,Iis box
i Homeowners who submit this affidavit indicaiing they arc dorng all work and thcn hirc oubide conrractors mustiubmrt a new afiidayit indicali ng suchmusi anached an adiitional sh Saveempioyees- Iithe sub-conlracio.s hale snDlcve.conp ,Dolrcy number
I am an employer that is proyiding work
information,ers' cohpeftsatiott insurancefor my employees- Below is the policy qndjob site
Insurance Company Name
Policy # or Self-ins. Lic. #
Job Site Address:==--
Attach a copy or f*o,lt"tffi,l"r,,*.;"*-o*,." *",.Failure to secure.coverage as required under MGL c. 152, g25A is a criminal violatior: punishable by a fine up tc $1,500.00and'/or one-year imprisonment, as well as civil penalties in ihe form of a STop \voRK oRDER anj a fine of up ro s250.00 aday against rhe violator. A copy ofthis statement aray be forwarded tc the office of investigations ofthe DIA for insurancecoverage verification.
I do hereby certify under tlte pains aru! penalties o peiury thLt the i farnntio
Si
P ) -3o13/'7
n prot,ided above is true and correct,
Date /7
use onlt. Do not wtite in this area, to be completed by ciy ot to\)n oflicial
lssuing Authority (circle one):
1. Board of Heatth 2. Building Deparrmenr 3. City/Town Clerk
6. Other {. Electrical Inspector 5. Plumbing lrspector
Phone #:
OfJicial
City or Town:
Contact Person:
Permit/License #
A'!'E-
Are you tn employcr? Check th. appropriatc bor:
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g a<tanmon*ea[rr Ol liassachr,,elts
Dryrs|on ot Occupaltoaral Lrcanst,reBoard ot 9g116,n, l*rlatlons and St.nda.os: " -s$"11 u,.S 1r
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HOiIE ITIPROVEUE}rI C]NTNACIOF
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