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Home My WebLink AboutApplicationPermit# Office Use Only /Db.o7) Permil cxpircs l8o days frorn issuc dalc 6LDY-J CONSTRUCTION ADDRXSS ASSESSOR'S INFOfuVATION EXPRESS BUILDING PERMIT APPLICAT TOWN OF YARMOUTH Yarmouth Building Department I 146 Route 28 South Yarmouth , MA 02664 (508) 398-2231 Ext. 1261 ul e,4(A,<- 9 ,.tr Map tL! lq u/ MENT c JAll 01mh EIVE D "(* r*/.uc(l;r o {/2 N PRESTNT DRESS TEL } CONTRACTOR NAr\'tE V(esidential !!AILNG ADDRESS TEL, # D Commercial Est. Cost ofConstructiol $a DDL) Ilome Improveme[t Contrector Lic. # Construction Supervisor Lic. #-- n I have Worker's Compensation Insurance Insuraoce Company Najne: _ Worker's Comp. policr.# WORKTO BE PERT'ORNIED Tent _ Duration vsidiDg: # of Squares Roofing: # of Squares_ ( _ Old Kings Highway/Historic Dist. (Fire Retardant Certifi cate attached?) Replacement wind onr't *-l/ Pool fencing ) Remove existing* (mar. 2 layers) ( ) Replacirg like for like rThe debris will be disposed ofat:kr Loc,ofFacilit_v I declare under pena.lties of perjurr.-that lhe stat€ments herejn contained are irue and correct to the best ofmy knowledgc and belief I u.derstand that any faisc answe(s) for prosecution under lvlC.L. Ch. 268, Section IApplicant's Signature Owtrers Signeture (or rtt:rrhment I Dat€: Dat.: DateApproved By CrtCllo--1- @ i re.le.-r-// Building Official (or desisnee)E]VAIL ADDRESS Zoning District: Historical Dislrict: a Yes - No Flood Plain Zone: a Yes I No lVater Resource Protection District I Yes iNo Within 100 ft. of Wetlands:a Yes - No Hrl/l Parcel: Workmgr's Compensalion Insurancei (check one) E I am the homeowlcr - I am rhe sole proprietor Wood Stove -/ Replacement doors, * J ' Insulation will bejust causc lor dcnial or rcvocation ofmy license The Commonwealth of Massachusetts D ep artment of I nd ustrial 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 WITH THE PERNIITTING -ALITHORITY. ADDlicant Information Please Print Leeiblv ,/Name (Business/Organization/lndividual) i Address: ll 14 ud. lt ?.'(r' Arr you aI employer? Check the appropriate bor: l.[ I am a employer with _employees (full and/or pan-time).r I I am a sole proprietor or parbership and have no cmployees workin a homeowner doing all work myself [No worke6' comp. insurance ,equired.] i 4.! I am a homeowner and will be hiriry cont-actors to conduct all work on my propeny. ensure that all conts-actols either havc wodrcrs' compcnsation trs1llance or arc sole Foprictors with no crnployees. I am a general contacoa and I have hired the sub-conEactors li$ed on the attachcd sheel These suLconEactors have employees and have workers' comp. insuralce.l We are a corporarion and its officers have exerciscd 6eir righ! ofexcmptjo, per MGL c. I52, gl(4), aid we have no employees. [No workcrs' comp. insurance rcquircd.] I will ) 6 6: g for me in capacity. fNo workers' comp. insurance required.] City/State/Zip: .Any applicant lhat check box #l must also fill out thc sectjon be T Hodeovters ]lto submit rhis afrdavir indicaring thcy are dolag tont_acors tlrat check this box ilust a$ached an additional sheei employecs. ifthc suucont'actors have e LII ZZ Type of project (required) Z. f, New consfuctior 8. I Remodeling 9. L--l DemoLrtron l0 1l 12 Buiiding addition Electrical repairs or additions Plumbing repairs or additions 13. f Roofrepairs I4.E Other Phone #: low showing thair workers' coEpensalion policy infoamatiorL all work and tren hirr ouBida conE-actors must submit a new affidavit indicating such showiflg tllc name of the sub-conEactors and statc whcther or not lhosc cntihcs bave mployees, they must prcvidc their workcrs'comp. policy number Job Site Address: C:ry/State./Zio:_ Attach a copy ofthe workers' compensation policy declaration page (sbowing the policy numbei and expiration date). Faiiure to secue cover€e as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00 aDd/or one-year imprisonment, as well as civil penaliies in the form of a STOp WORK ORDER and a fine of up to $250.00 a day against the violator. A copy ofthis statement may be forwarded to the Oftice of lnvestigations of the DIA for insurance coverage verificatton I do hereby Si ature: Phone l tlrc pains and penalties of peiury that the information provided above is trud and conect. Date # Official use only. Do not write in this area, to be completed W citl or town official. City or Town: permit/License # Issuing Authority (circle one): I. Board ofHealth 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing lnspector 6. Other Phone #: I am an emplqter thal is providing worken' compensation insurance/or my enEloyees. Belov, is the poticy andjob siteinformttion- Insurance Company Name : Policy # or Seif-ins. Lic. #: Expiration Date:_ Contact Person: