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Home My WebLink About100 Indian Memorial Dr Express Building Permit 10.9.2014(a, Y {��M4h.TTACn ESF�� EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: OWNER: CONTRACTOR: Map: Parcel: PRESENT ADDRESS /Cc,SN MAILING ADDRESS TEL # TEL. # Office Use Only Permit# Amount Permit expires 180 days from issue date Email Address: Email Address: Residential Commercial Est. Cost of Construction $ Home Improvement Contractor Lie. ##fir 3 Construction Supervisor Lie. # Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: �`/ �[y �' Worker's Comp. Policy# AIM— S 40 — 12 d T3 3 3 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: # of Squares Replacement windows: # Replacement doors: # Roofing; # of Squares ( ) Remove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( ) Replacing like for like *The debris will be disposed of at: dt G no � / 02es & I � ^� LF LocAion of Facility 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 re�of my license and for prosecution under M.G.L. Ch, 268, Section 1. Applicant's Signature: Cy� Date: �� // Owners Signature (or attachment) � Date: Approved By: Date; Building Official (or designee) District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft. of Wetlands: Yes No Yes No The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ARyficant Information Please Print Legibly Name (Business/organization(rndividuai): /0C/�L14 Address: A / p�c /� e� _ � City/State/zip:Phone #: Are you an employer? Check the appropriate box: 1. am a employer with - �- 4. ❑ I am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6• ❑ New construction 2. ❑ I am a sole proprietor or partner- . listed on the attached sheet 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. 615emolition working for me in any capacity. [No workers' comp. insurance employees and have workers' comp. insurance.: 9. [] Building addition require&] 3. ❑ I am a homeowner doing all work 5. ❑ We are a corporation and its officers have exercised their 10.❑ EIectrical repairs or additions myself. [Na workers' camp. . right of exemption per MGL 11.❑ Plumbing repairs or additions insurance required.] t 3a. ❑ I am a homeowner acting as a c. 152, § 1(4), and we have no employees. [No workers' I2 ❑Roof repairs 13.0 Other general contractor (refer to #4) comp. insurance reouired_1. 'Any applicant that checks box #I must also fill out the section below showing their workers' compeasation`po6cy information Homeowners wits submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box most attached an additional sheet showing the name Of the sub -contractors and state whether or nut those entities have emp]oyees. If the sub -contractors have employees, they must provide their workers comp. policy r olic number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and jab site information Insurance Company Name:l?G-S� Policy # or Self -ins. Lic. #: (NCIC' -- j Ud- S'dD 33 Expiration Date: -7-) L - f 3 Job Site Address: 1 Dd - -j "I- f rat-, 2 � r , K City/StatelZip: Attach a copy of the Workers'compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi der he pains and p nalties of perjury that the information provided above is true and correct Si afore: Date: /Ce . Official use only. Do not write in this area, to be completed by city or town officiat City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #.