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EXPRESS SHED PERMIT APPLICA N't'owN ot, Yn RMOU',I'l I
Ynrmouth Building l)cpnrtmcnt
I l.{6 Route' 2tl
South Yarnroutlr. MA 02661
(50t1) 398-223 I li\t. l26l
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ocT 31 2023
MENT
EIVED
BUILDING DEPART8y
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s-\The Commonwealth o/ Massach usetts
Department of Industrlal Accldents
1 Congress Steet, Suilc 100
B osto n, IttA 0 2 1 l4-2 0 I 7
www,mass,gou/dia
\Vot'kers' Compcnsedon tnsurrncc Aff,dgvit: BuitdcrdContrrctorr/Ehctrlehns/? Iumbcn.. TO BE FILED WITH TEE PERMITTING ATTTHORTTY.
ame (BusincsyorgrnizationlDdividusl):li s7 *^Jddress:
CitylStatelZip :5o"yt \ayptost(pvfi phonc#r Z7'/ 968 o6 7 7
Typc of prolcct (rcqulrcd):
7. I Ncw onstruotion
8. fl Rcmodclin3
9. E Dcrnolition
l0 ! Building eddition
t l.E Eloccical rcpain or additions
I 2. ! Plurubing reprirs or additions
13.!Roofrcpain
l4.E Other
'Any $plic! Olrl cbcclst Homaowim who cubmit
tonEr.toB hlt chcck diis
bo( I I murt also fill out rhc rction bclov rhowing
hir rf6drvit indicuing thry ui doiDg dl r,L,ort md
box must ltr.chcd lrl .dditionll th!.t iho'\riDg th.
$cir \,,orkcn' coraFoturdon polisy inlormrtion
thcn hitc oualda sonmr@r mult lubmlt l rllw rtli&vit hdicrint tucll
nlrrlo of th. sub.lootEcto6 rnd 3ttt! \phGtlrcr or not thor! cnti&t hsv.
crnplqycet. lf thc luEconElcloR hrvc cmployc.!,tEy rnr-st provido thcir workr:' conp. policy nlurbrr
I an aa cmploycr that b prcvdhg vorkcn' conqatsalon lnsurorccJor nty anployccs, Bclontt tt lh. pollc! andlob stetnlormalon-
Iosuraacc Cooprny Naoc: -
Policy # or Self-ins. Lic. #:Expiration Drtc:_
Job Sitc Addrcss: Ciry/Srstdzip:_
Attech a copy ofthc workers' compensrtiou policy dcclaration prgc (!howi!g ths poticy numUcr rnd crptretiou a*4.
Failurc to securs coveragc as required undcr MGL c. 152, g25A is a criminal viol*ion punishable by a fine up to $ 1,s00.00
aad./or ooc-ycar imprisonmout, as wcll as cMl pcnaltics in thc form of a STOP WORK ORDER and a finc ofup to $250.00 aday against thc violator. A copy ofthls stltsnent may bc fonrardod to the Ofricc of Invcstigrtionr oftho DLA ior iusuurcc
covorago verification.
do hueby
Phone #:
nder th nt of perjury tha the lnformation prcvldcd abovc b truC and. conecL
/o
Offrdal use onl!, Do not N,rlte in thb arca, to be complacd by cte or tatn olficlal
City or Town: _ pcrmlULlccnsc #
Issulng Authortty (ctrclc olc):I' Board of Hcaltb 2. Buildlng Dcp.rtncnt 3. clty/Town clerk 4, Elcctricrl Inrpcctor 5. plumblng Inspect,r6. Othcr
Contact Person:
Ar. you rD .mploy.r? CtlcL th. rpproprLt! bol:
l.! t rm r oraploy* nidr
-cmployocs
(full rnd/or prn-tim)..
2.E I lra s rolc psop.ictor or plnnuthip ud hrvc no omployccs wo*ing for ma in
,rny crp.city. [No uo*rfs' c.mp. inlunnc. GquirEd.]
f .$ I m r tromwncr doir! dl uo* myrl( [No eod.rn' comp. intutucc Gquind.l r
l. ! I rm a tronrconncc rd will bc hfint contnrb'S to oorduc tll rcrk on tny Fo?Gfiy. I will. .nr[rr! drrl dl contrEtoE oi$.r hrvc uErtrru' campeotltion itEotrlc! or g! toh
, popriur with no aployru.
5. n I rll ! gqrcrrl conctfior lrd I hrvc hilod tbc ruEconmrton liccd on th! tircl*d $.d.- Thc& $bconElc$s htvc rEploycc! llld h.vc rrrorklft' coap. ir.Euucr,I
6.[ Wc uc r corporetio! .nd in ofllclr! hsv? cxrccircd thoh riglrt ofc*arnpdon pcr MOL c.
152, ll(4), urd wr hrvq rlo lriployrca, [No l,ortcn' comp. innlrocl rcquind.]