HomeMy WebLinkAboutExpress Building App 50 Park• The Commonwealth of Massachusetts
Department of IndustrialAccidents
kwi I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
�4nolicant Information Please Print Legtbiv
Name (Business/OIXization/Individual): �np��p CC�Ylsfyt�c�lc}n
Address: 'Nv '& x
City/State/Zip-_&k he l na A r►,4vc9 PhnnP df• 1... r q (oS l9 n b'
Are you an employer? Check the appropriate box:
1lgram a employer with _employees (full and/or part-time).*
2.E]1 am a We proprietor or partnership and have no employees working for me in
any capacity. (No workers' comp, insurance required.]
3. [:]1 am a homeowner doing all work myself (No workers' comp. insurance required.] t
4.[31 am a homeowner and wdl be hiring contractors to conduct all work on my property. I wal
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. 1 am a general corms= and I have hired the sub -contactors listed on the attached sheet
These have employees and have workers' comp. insuraomt
6.❑We arc a corporation and its officers have exercised their right of exemption per MGL c.
152, $ I (4). and we have no employees. [No workra
ers' comp. insunce required.]
Type of project (required):
'I. [RKew construction
8. [] Remodeling
9. [}0emolition
10 0 Building addition
I LEDElectrical repairs or additions
12. Q Plumbing repairs or additions
13. Q Roof repairs
14. []Other
t
- � -,-�-..-�-�- ••.............� K W us & mi also nu out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and than 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 whaher or �t those entities have
employees. If the sub-conractors have employees. they must provide their W od=' comp. policy number.
I am an employer thatisproviding workers' conrpensadon insurancefor my employees: Below is thepoUcy andjob site
information.
Insurance Company
Policy # or Self -ins. Lic. #:W C 1114 3itl -off Ckal l} Expiration Date: I v Ia-O/aa
Job Site Address; DAL4C K }lIP ni , a City/State/Zip:_1JCS4- ycCM( X-,&-f-(mil
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 certijy,icnder the pains andpe nalties ofperjury that the information provided above is true and correct
Official use only. Do not write in this area, to be completed by chy or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6.Other
aa-
4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #•
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: �CQ
ASSESSOR'S INFORMATION:
Map: a0 Parcel: "73
OWNER:akS n*V4--J -+)Ct7l1Sl
NAME
CONTRACTOR: NNAME Carp
esidential [7 Commercial
Est. Cost of Construction
Office Use Only
Permit#
Amount
Permit expires 180 days from
issue date
Home Improvement Contractor Lie. # 1 7-7 % % 3 Construction Supervisor Lie. #CSFA - /Obl,37
Workman's Compensation Insurance: (check one)
D I am the homeowner [3 I am the sole proprietor GYihave Worker's Compensation Insurance
Insurance CompanyName:P55LXIQk-,d C/11&IAQt & JMLJC ✓1rP_ Worker's Comp. Policy# 41) f SiNo�f3e1-o?Ua/�
WORK TO BE PERFORMED
Tent II Duration (Fire Retardant Certificate attached?)
Siding: # of Squares
Replacement windows: #.
Roofing: # of Squares (❑) Remove existing* (max. 2 layers)
Old Kings Highway/Historic Dist. ([3) Replacing like for like
*The debris will be disposed of at:
Location
Wood Stove_
Replacement doors: #,
Insulatioq—El
Pool fencing__
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 rNocaGon of my license and for prosecution under M.G.L. Ch. 268, Section 1.
F
Applicant's Signature:
Owners Signature (or
Date: 31,3ol a a
Approved By:
Date:
Building Official (or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft. of Wetlands:
❑ Yes 0 No 0 Yes 0 No
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